Updated March 9, 2018.
One of the most common causes of disability is chronic back pain. We have all hurt our back at one time or another. We take it easy for a few days or few weeks and fully recover. However, for some individuals back pain is chronic, severe and debilitating.
The spine is tremendously important because it provides the physical support for our entire body. The spine has five parts – cervical, thoracic, lumbar, sacrum and coccyx. Spinal vertebrae are bones that form an opening in which the spinal cord passes. These bones are stacked one on top of another.
The two parts of the back that most often cause problems are the cervical spine (neck) and lumbar spine (low back). The cervical spine has 7 vertebrae that support our neck and skull. They allow us to twist our head up and down, and turn it right and left. The lumbar spine has 5 vertebrae that allow us to bend and twist our backs.
The vertebrae are held together by ligaments. In between the vertebrae are cushiony discs that act as shock absorbers. Each vertebra has two facet joints. A facet joint has two bony surfaces with cartilage between them and a capsule of ligaments surrounding it. The facet joints and disc form a three joint complex near each vertebra.
The primary reason back pain is a common cause of disability is that the spinal structure contains many potential pain generators. Here is a list of some of the most common pain generators.
1. Bulging or ruptured discs. Each disc contains an inner core of a soft jelly-like substance called the Nucleus Pulposus and a tough outer band called the Annulus Fibrosus. Due to normal aging, trauma, or both, the tough fibers can tear causing a bulge or tear in the disc. If the Nucleus Pulposus presses against a spinal nerve, pain is generated. Further, if the Nucleus Pulposus escapes into the spinal canal it often irritates the spinal nerves and causes additional pain.
2. Disc desiccation. The Nucleus Pulposus is about 80% water. As we age discs gradually lose fluid. This is a normal part of the aging process that we all experience. As a result of this loss of fluid, the discs degenerate to a degree. Hence, the term degenerative disc disease. As discs degenerate, the space between vertebrae shrinks. This is referred to as loss of disc height. Disc desiccation and loss of disc height can be pain generators.
3. Soft tissue injuries. The bones of our back are connected via a complex assortment of muscles, tendons, ligaments and cartilage. A ligament is tissue that attaches bone to bone. A tendon is tissue that attaches muscle to bone. A muscle is flexible tissue between joints that allows movement. Cartilage is tough but flexible tissue that covers the ends of bones at a joint. Healthy cartilage promotes movement by allowing bones to glide over each other. All these tissues are often referred to as “soft tissues”. A tear in any of these tissues can cause pain.
4. Spondylolisthesis. Spondylolisthesis is a degenerative condition in which a vertebra becomes displaced and moves forward or backward. In most cases, spondylolisthesis occurs when the soft disc that separates vertebrae deteriorates. Spondylolisthesis causes a malalignment of the spinal canal. Nerves can become squeezed or trapped thereby generating pain.
5. Facet Hypertrophy. Facet Hypertrophy is a degeneration and enlargement of the facet joints. As the body ages the facets may become arthritic and develop bony growths that narrow the spaces where nerves exit the spine. This narrowing can squeeze the nerve causing pain in the back or down one or both legs. Further, facet hypertrophy can cause the facet joint to become misaligned. Misaligned facets can cause surrounding muscles to tighten and spasm, thereby causing back pain.
6. Spinal Stenosis. Spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal. This narrowing can cause pain, numbness, paraesthesia (pins and needles), and loss of motor control. The location of the stenosis determines which area of the body is affected.
7. Piriformis syndrome. The piriformis muscle is behind the hip joint and aids in the rotation of the hip. This muscle and the sciatic nerve cross each other behind the hip in the deep buttock. Dysfunction of the piriformis muscle causes pain in the sciatic nerve distribution (i.e. in the gluteal area, posterior thigh, posterior leg, and lateral aspect of the foot).
The Listings. The starting point in disability analysis is to determine whether the back condition meets SSA’s Listing of Impairments 1.00 on the Musculoskeletal System. If an individual meets the criteria of a Listing within 1.00, SSA awards disability benefits. However, this is pretty rare.
Residual Functional Capacity (RFC). If an individual does not meet one of the Listings within 1.00, the legal issue is whether degenerative disc disease, alone or in combination with other impairments, prevents the individual from engaging in substantial gainful activity. The primary question is does the individual have the RFC to perform his/her past relevant work (Step 4) or other work (Step 5)?
Almost always, back cases become what are legally referred to as “chronic pain” cases. The Social Security Administration (SSA) recognizes that chronic pain can be a cause of disability. However, the burden of proof is on the individual, not SSA, to produce evidence of disabling pain. The kinds of evidence SSA considers includes the following:
1. The limitations in daily activities caused by chronic pain;
2. The location, duration, frequency, and intensity of the pain;
3. Factors that precipitate and aggravate the pain;
4. The type, dosage, effectiveness, and side effects of medication the individual takes or has taken to alleviate pain;
5. The number and variety of treatments or medical procedures the individual receives or has received for relief of pain;
6. The number of visits to health care providers seeking pain relief.
7. The number of different health care providers the individual has seen in an effort to find pain relief.
8. The emotional impact of chronic pain.
For more information on how SSA evaluates pain, see SSR 16-3p.
1. Get treatment by an orthopaedic doctor, and follow his/her advice. Over the years I have met with many prospective clients seeking disability benefits due to back pain who have never been examined by an orthopaedic doctor. When one sustains a severe back injury, seeking disability benefits should be the last resort. The first option should be seeking treatment from an orthopaedic specialist. Most back problems are treatable. With treatment, most people can return to work.
Physical therapy, epidural steroid injections, surgery, and home exercises, are very effective treatment modalities. Returning to work is more financially rewarding and personally meaningful than drawing disability benefits. Further, an Administrative Law Judge (ALJ) is more likely to award benefits if an individual has exhausted all treatment options under the management of an orthopaedic specialist, and still experiences debilitating back pain.
2. Get an MRI. An MRI refers to a magnetic resonance imaging test involving magnetic waves that create highly detailed images of the spine. MRIs are incredibly informative as to what is going on with the soft tissues of the spine. MRIs provide considerably more information than a plain x-ray. In my opinion, an MRI is an essential test to the effective diagnosis and treatment of a severe back injury. Moreover, an MRI that documents one or more pain generators is valuable evidence in winning a chronic pain case.
3. Pain Medication. The importance of pain medicine in the treatment of chronic pain is controversial. Powerful pain medicine can have powerful side effects. Narcotic pain medicine is additive. There are different opinions within the medical community as to the how much or how little pain medicine should be used in the long term treatment of chronic pain.
Unfortunately, I have not seen a wide variety of opinion among ALJs on this subject. My experience has been that if my client is not taking strong pain medicine, the ALJ often does not believe his or her testimony about debilitating pain.
In summary, degenerative disc disease and Social Security disability is a complex subject. It is impossible to address all of the relevant considerations in a single blog post. If you have degenerative disc disease and are considering applying for disability benefits, feel free to contact me for a free phone consultation.