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C&P Exam Prep: Spondylolisthesis or Segmental Instability (Cervical)

DC 5239 musculoskeletal 38 CFR 4.71a

DBQ Overview

Interview + Physical
Form Name
Neck_Conditions_Cervical_Spine
Form Code
Neck_Conditions_Cervical_Spine
Page Count
14
Examiner Type
Physician or Physician Assistant
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current severity of your cervical spondylolisthesis or segmental instability under DC 5239, establish nexus to service if not already rated, and capture all orthopedic and neurological manifestations that drive the disability rating under the General Rating Formula for Diseases and Injuries of the Spine (38 CFR 4.71a).

What the examiner evaluates:

  • Active and passive range of motion (ROM) for all six cervical planes: forward flexion, extension, right and left lateral flexion, right and left lateral rotation
  • Pain onset angle and whether pain limits motion before the anatomical end-range
  • Functional loss due to pain, fatigability, weakness, incoordination, or lack of endurance during and after repetitive use
  • Muscle spasm, guarding, tenderness, and presence of abnormal spinal contour or abnormal gait
  • Neurological examination including upper-extremity reflexes (bicep, tricep, brachioradialis), motor strength, and sensory findings for C5-C6, C7, and C8-T1 nerve root levels
  • Radiculopathy signs: radiation of pain, numbness, or tingling into the upper extremities
  • Use of assistive devices (cervical collar, brace, cane, walker, wheelchair)
  • Incapacitating episodes and bed-rest history in the past 12 months (for IVDS coding if applicable)
  • Flare-up frequency, duration, and severity as described by the veteran
  • Impact of the condition on occupational and daily functioning

The exam will typically begin with a seated interview about history and symptoms, followed by a physical examination in a standing or seated position for ROM testing. The examiner will likely use a goniometer or inclinometer to measure angles. The cervical spine is not a weight-bearing joint in the traditional sense, but the DBQ does capture weight-bearing vs. non-weight-bearing ROM distinctions. If the examiner attempts any provocative neurological testing (Spurling's test, shoulder abduction relief sign), note whether it provokes pain or neurological symptoms.

Typical duration: 30-45 minutes

Cervical Forward Flexion (Active)

How far you can bring your chin toward your chest; normal is 0-45 degrees.

What to expect:

The examiner will ask you to bend your head forward as far as you comfortably can. They will measure the angle at the endpoint using a goniometer or inclinometer. They must also record the angle at which pain begins if pain limits motion before the end-range.

Key thresholds:

  • Greater than 15- but not greater than 30- — Satisfies 20% threshold under General Rating Formula when combined with other criteria
  • 15- or less — Satisfies 40% threshold under General Rating Formula
  • Pain onset before end-range — Examiner must note DeLuca factors; functional loss due to pain can substitute for measured limitation

Tips:

  • Perform the movement at your true maximum - do not push past your pain point to appear cooperative.
  • Immediately tell the examiner the degree at which pain begins, not just where you stop.
  • If your pain or stiffness is worse in the morning or after prolonged activity, state that the exam represents a relatively good moment.
  • Ask the examiner to also measure passive ROM (them guiding your head) to capture any difference.

Pain considerations: Under DeLuca v. Brown and 38 CFR 4.40/4.45, pain, weakness, fatigability, incoordination, or lack of endurance that restricts motion must be considered functional loss. If pain stops your motion at 20-, that 20- is your functional ROM even if anatomically you could go further with sufficient discomfort.

Cervical Extension (Active)

How far you can tilt your head backward; normal is 0-45 degrees.

What to expect:

You will be asked to tilt your head back as far as possible. Extension is often more limited than flexion in spondylolisthesis due to foraminal narrowing that worsens with extension.

Key thresholds:

  • Greater than 15- but not greater than 30- — Combined with other reduced planes, supports 20% rating
  • 15- or less — Supports 40% rating level

Tips:

  • Extension in spondylolisthesis frequently provokes neurological symptoms (electric shock sensation, arm numbness); describe these symptoms immediately if they occur.
  • Do not suppress a grimace or verbal expression of pain - these are legitimate clinical data.
  • If extension causes radiating pain into the arm or produces a Lhermitte-like sensation, tell the examiner immediately.

Pain considerations: Extension narrowing the spinal canal or neural foramina is a hallmark of spondylolisthesis. Neurological provocation during extension is clinically significant and should be verbally reported during the exam.

Right and Left Lateral Flexion (Active)

How far you can tilt your ear toward each shoulder; normal is 0-45 degrees each side.

What to expect:

The examiner will measure each side separately. Asymmetry between sides is clinically meaningful.

Key thresholds:

  • Greater than 15- but not greater than 30- — Supports 20% rating when combined
  • 15- or less — Supports 40% rating level

Tips:

  • Lateral flexion toward the side of your radiculopathy commonly aggravates symptoms; report this.
  • If one side is significantly worse, explain why (e.g., nerve root compression on that side).
  • Passive ROM may be greater than active ROM; request the examiner test both.

Pain considerations: Pain provocation during lateral flexion, especially toward the symptomatic side, should be reported with a numeric descriptor (0-10 scale) and location (e.g., radiates into right arm to the elbow).

Right and Left Lateral Rotation (Active)

How far you can turn your head to each side; normal is 0-80 degrees each side.

What to expect:

You will be asked to look as far over each shoulder as possible. This is the plane most commonly limited in cervical spondylolisthesis.

Key thresholds:

  • Combined bilateral rotation reduced — Contributes to overall severity assessment under General Rating Formula

Tips:

  • Rotation is often limited on the side of nerve root compression; be specific about which side is worse.
  • Note if turning your head causes dizziness or visual disturbance (vertebrobasilar involvement).
  • Report if sustained rotation (e.g., looking over shoulder while driving) causes tingling or arm weakness.

Pain considerations: Report pain onset angle for each side. If rotation-induced pain causes you to avoid driving or certain activities, describe this functional limitation explicitly.

Passive ROM Testing (All Planes)

Examiner-guided range of motion to compare with active ROM. If passive > active, functional loss due to DeLuca factors is implied.

What to expect:

The examiner gently moves your head through each plane. You should relax and not resist, but speak up if pain occurs at any point.

Key thresholds:

  • Passive ROM exceeds active ROM — Supports finding of additional functional loss attributable to pain, fatigability, or weakness beyond measured active ROM

Tips:

  • Verbally report pain immediately when it begins during passive motion.
  • If passive ROM is the same as active ROM, tell the examiner that your muscles voluntarily guard at that point due to pain.
  • If the examiner skips passive testing, politely note that you would like it documented.

Pain considerations: Per Correia requirements and 38 CFR 4.46, passive ROM must be documented in the DBQ. If not performed, the examination may be inadequate for rating purposes.

Repetitive Use ROM Testing (3 Repetitions)

Whether ROM degrades after repeated motion due to fatigue, pain, or weakness - a core DeLuca factor.

What to expect:

You may be asked to perform the same motion three times in succession. The examiner measures whether your ROM decreases with each repetition.

Key thresholds:

  • ROM decreases with repetition — Demonstrates DeLuca-based functional loss; examiner must document this in the DBQ flare-up/functional loss section

Tips:

  • If your ROM worsens with repetition, point this out to the examiner even if they do not ask.
  • Describe post-activity pain increases: 'After moving my neck three times, the pain jumps from a 4 to a 7 and my arm starts tingling.'
  • If repetitive use at work causes increased pain or stiffness by day's end, describe this even if the exam is conducted in the morning.

Pain considerations: This is one of the most underutilized DeLuca factors. Many veterans perform well at a single measurement early in the exam but have significant degradation with activity. Explicitly mention your typical end-of-workday or post-activity functional level.

Upper Extremity Neurological Examination

Deep tendon reflexes (bicep C5-6, brachioradialis C6, tricep C7), motor strength in upper extremities, and sensory examination for dermatomal patterns.

What to expect:

The examiner will tap your tendons with a reflex hammer (bicep, tricep, brachioradialis) and test grip strength, finger abduction, and shoulder/elbow muscle groups. They may test light touch or pinprick sensation along your arms and hands.

Key thresholds:

  • Absent or decreased reflex(es) — Objective neurological finding supporting radiculopathy; rated separately under DC 8510-8516 as a secondary condition
  • Motor weakness (0-4/5 strength) — Graded separately; mild/moderate/severe weakness carries separate rating percentages
  • Sensory loss in dermatomal pattern — Supports radiculopathy diagnosis and separate evaluation under peripheral nerve DCs

Tips:

  • Before the exam, note the exact distribution of any numbness, tingling, or weakness (e.g., thumb and index finger = C6; middle finger = C7; ring and small finger = C8).
  • Report all neurological symptoms even if they are intermittent; tell the examiner your worst day frequency.
  • If you have experienced hand weakness that causes you to drop objects, describe specific instances.
  • Disclose any prior EMG/nerve conduction study results; bring copies if available.

Pain considerations: Radiculopathy evaluated separately from the spinal condition itself under the General Rating Formula. Separate evaluations for orthopedic (5239) and neurological (peripheral nerve DC) manifestations are required per M21-1 V.iii.1.B.3.a.

Estimate

Rating Criteria Breakdown

50% Unfavorable ankylosis of the entire cervical spine. The enti ...

Unfavorable ankylosis of the entire cervical spine. The entire cervical spine is fused in a disadvantageous position.

Key Symptoms

  • Complete cervical fusion in non-neutral position
  • No volitional neck movement in any plane
  • Severe occupational and daily living impairment
  • Dependence on assistive devices for ambulation safety
  • High cervical involvement with myelopathic symptoms

CFR: A 50% rating requires unfavorable ankylosis of the entire cervical spine - complete fusion of all cervical segments in a disadvantageous position. This is the maximum rating for isolated cervical orthopedic pathology under the General Rating Formula, though separate neurological ratings may apply concurrently.

40% Unfavorable ankylosis of a portion of the cervical spine. Un ...

Unfavorable ankylosis of a portion of the cervical spine. Unfavorable ankylosis means fusion in a position other than neutral (e.g., forward flexion, lateral deviation, or rotation), resulting in functional impairment greater than neutral fusion.

Key Symptoms

  • Cervical spine fused in a non-neutral/disadvantageous position
  • Head fixed in flexion, rotation, or lateral tilt
  • Inability to look forward or upward
  • Severe impact on driving, occupational performance, and activities of daily living
  • Complete loss of volitional cervical motion

CFR: A 40% rating requires unfavorable ankylosis of a portion of the cervical spine - fusion in a position other than neutral that creates functional disadvantage. This is distinct from the 30% favorable ankylosis (neutral position fusion).

30% Forward flexion of the cervical spine 15 degrees or less; OR ...

Forward flexion of the cervical spine 15 degrees or less; OR, favorable ankylosis of the entire cervical spine. Favorable ankylosis is fusion in a neutral position (0 degrees).

Key Symptoms

  • Severe restriction of cervical flexion (15 degrees or less)
  • Near-complete loss of neck mobility across multiple planes
  • Constant pain requiring daily medication
  • Inability to perform overhead work or sustained neck-down positions
  • Significant gait disturbance related to cervical instability
  • Frequent radiculopathy flares requiring rest

CFR: A 30% rating requires forward flexion of 15- or less, or favorable ankylosis. This reflects near-complete loss of functional cervical motion. For DC 5239, segmental instability may result in protective muscle guarding so severe that functional motion approximates this threshold.

20% Forward flexion of the cervical spine greater than 15 degree ...

Forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; OR, the combined range of motion of the cervical spine not greater than 130 degrees; OR, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliotic deformity, kyphosis, or other abnormal contour.

Key Symptoms

  • Moderate restriction of cervical flexion (15-30 degrees)
  • Antalgic posture with visible cervical guarding
  • Visible muscle splinting causing head tilt or asymmetric posture
  • Combined ROM -130 degrees total across all cervical planes
  • Frequent pain interfering with sustained activity
  • Visible abnormal spinal contour on examination

CFR: A 20% rating under the General Rating Formula requires forward flexion 15-30-, or combined ROM -130-, or muscle spasm/guarding resulting in abnormal gait or spinal contour. This is a critical threshold where visible objective findings become necessary.

10% Forward flexion of the cervical spine greater than 30 degree ...

Forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; OR, combined range of motion of the cervical spine not greater than 170 degrees; OR, muscle spasm, guarding, or rigidity without abnormal contour of the spine; OR, vertebral body fracture with loss of 50 percent or more of the height (when applicable). Note: DC 5239 is rated under the General Rating Formula for Diseases and Injuries of the Spine.

Key Symptoms

  • Mild restriction of cervical flexion (30-40 degrees)
  • Muscle spasm on palpation without visible spinal deformity
  • Guarding with motion that does not produce abnormal spinal contour
  • Combined ROM moderately reduced (-170 degrees total)
  • Intermittent neck pain with activity

CFR: Under the General Rating Formula, a 10% rating requires forward flexion greater than 30- but not greater than 40-, or combined ROM -170-, or documented muscle spasm/guarding without abnormal contour. DC 5239 is evaluated by analogy using this formula.

How to Describe Your Symptoms

Pain - Location, Quality, and Severity

How to describe:

Describe the location (posterior neck, base of skull, between shoulder blades, radiating down one or both arms), quality (sharp, stabbing, burning, aching, electric), and severity on a 0-10 scale. Be specific about whether pain is constant or intermittent, and what triggers or relieves it.

Worst-day example:

“On my worst days, I wake up with a 7/10 burning pain at the base of my skull that radiates down my right arm to my thumb and index finger. I cannot turn my head to the right to check traffic when driving. The pain spikes to 9/10 if I look up or reach overhead. I need 400mg of ibuprofen and a heating pad before I can function.”

What the examiner listens for:

Specific dermatomal radiation patterns that indicate nerve root involvement (C5 = lateral upper arm, C6 = thumb/index finger, C7 = middle finger, C8 = ring/small finger). Consistency between reported symptoms and neurological exam findings.

Understatements to avoid:

Saying 'it's manageable' or 'I push through it.' These phrases suggest adequate function. Instead, describe what you are unable to do and what coping strategies you require.

Range of Motion - Functional Limitations

How to describe:

Describe specific activities you cannot perform or must modify because of neck motion restrictions. Use concrete examples: driving, overhead reaching, reading documents on a desk, looking up at a screen, sleeping.

Worst-day example:

“I cannot look over my right shoulder to change lanes safely, so I have stopped driving on highways. I cannot look down at my desk for more than 10 minutes without severe neck pain and right-hand tingling that forces me to stop. I sleep with a rigid cervical pillow and still wake up 3-4 times nightly from neck pain.”

What the examiner listens for:

Correlation between reported activity limitations and the measured ROM angles. The examiner is assessing whether functional limitations are proportionate to structural pathology.

Understatements to avoid:

Demonstrating more motion than you actually have on a typical day. Perform the exam as you would on an average or worse-than-average day, not a best-case day. State if today is a relatively good day.

Flare-Ups - Frequency, Duration, and Triggers

How to describe:

Describe how often flare-ups occur (daily, weekly, multiple times weekly), how long they last (hours, days), what triggers them (turning head, prolonged sitting, cold weather, physical activity, stress), and what happens during a flare (increased pain, neurological symptoms, bed rest requirement).

Worst-day example:

“I have severe flare-ups 3-4 times per week. During a flare, my neck locks in flexion, I get electric shooting pain into my right arm, and my grip weakens so badly I cannot hold a cup. Flares last 2-4 hours and require me to lie flat with a heating pad. About twice a month, a flare is severe enough that I spend 1-2 days in bed.”

What the examiner listens for:

Whether flare-ups have caused bed rest episodes in the past 12 months (relevant to IVDS incapacitating episode criteria if co-coded), and the frequency/duration pattern that establishes chronic rather than episodic disability.

Understatements to avoid:

Minimizing flare frequency. Many veterans say 'sometimes' or 'occasionally' when they mean multiple times per week. Use specific numbers and dates where possible.

Neurological Symptoms - Radiculopathy

How to describe:

Describe the exact distribution of numbness, tingling, burning, or weakness in each upper extremity. Note which fingers are affected, whether symptoms are constant or intermittent, and what activities provoke or relieve them. Describe any hand weakness, dropping objects, or coordination problems.

Worst-day example:

“My right thumb, index finger, and the radial side of my forearm are constantly numb - it never completely goes away. When I extend my neck or turn my head right, an electric shock shoots into my arm within seconds. I drop objects from my right hand without warning about twice a week. Writing, typing, and buttoning shirts are difficult because of the combination of pain and hand weakness.”

What the examiner listens for:

Dermatomal consistency (C5: shoulder/lateral arm; C6: thumb/index; C7: middle finger/tricep; C8: ring/small finger). Correlation between reported symptoms and reflex/sensory/motor exam findings. Objective neurological deficits that support a separate radiculopathy rating.

Understatements to avoid:

Saying 'just a little tingling sometimes.' Intermittent but significant neurological symptoms still warrant documentation and potential separate rating. Describe your worst presentation, not your mildest.

DeLuca Factors - Fatigability, Weakness, and Incoordination

How to describe:

Per 38 CFR 4.40 and 4.45, functional loss due to pain, fatigability, weakness, and incoordination must be considered even when ROM appears acceptable. Describe how these factors reduce your functional ability over the course of a day or after activity.

Worst-day example:

“Even on days when my neck feels relatively loose in the morning, after two hours of work requiring any neck movement, the muscles fatigue completely and I experience a 5/10 increase in pain with muscle trembling. By afternoon, I can barely hold my head upright without leaning against a headrest. This fatigue-induced worsening happens every single work day.”

What the examiner listens for:

Evidence that the veteran's functional capacity decreases over the course of a day or with repetitive use, which is not captured by a single-point ROM measurement at the beginning of an exam. The examiner should document this in the flare-up and functional loss sections of the DBQ.

Understatements to avoid:

Only describing your morning baseline. Most C&P exams occur in the morning when many veterans feel relatively better. Explicitly state: 'This exam is being conducted at my best time of day - my function is significantly worse by afternoon and after any sustained activity.'

Occupational and Daily Living Impact

How to describe:

Describe specific jobs, tasks, and activities you have had to stop, modify, or struggle with because of your cervical condition. Include both occupational (lifting, driving, computer work, overhead tasks) and personal (sleep, hygiene, childcare, recreation) impacts.

Worst-day example:

“I was forced to transfer from a supervisory role requiring frequent vehicle use to a sedentary desk position, but even desk work is limited to 90 minutes before neck pain forces me to lie down. I cannot participate in recreational activities I formerly enjoyed (swimming, hiking). I require my spouse's assistance to wash my hair because tilting my head back causes a near-blackout sensation.”

What the examiner listens for:

Concrete, specific functional limitations that map to rating criteria. The examiner will document occupational and daily living impact in the functional impact section of the DBQ (field 462).

Understatements to avoid:

Generic statements like 'it affects my quality of life.' Use specific, measurable impacts: 'I can sit for no more than 20 minutes,' 'I have missed X days of work per month,' 'I cannot drive more than 15 minutes.'

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to request a copy of the completed DBQ after it is submitted to the VA; request this through your regional office or online through VA.gov.
  • You have the right to record your C&P examination in states that permit single-party consent audio recording; verify your state's law before the exam date.
  • You have the right to submit a personal statement (VA Form 21-4138) detailing your symptoms, functional impact, and any deficiencies in the C&P exam to supplement the DBQ findings.
  • You have the right to request a second opinion or another C&P examination if the initial examination is inadequate - an inadequate exam is one where ROM planes are not all measured, DeLuca factors are not addressed, or neurological findings are not documented.
  • You have the right to have an accredited claims agent, attorney, or Veteran Service Organization (VSO) representative review your DBQ and assist you in identifying rating errors or exam inadequacies.
  • You have the right to a higher-level review or Board of Veterans' Appeals hearing if you disagree with the rating decision that results from this examination.
  • You have the right to submit buddy statements (VA Form 21-10210) from family members, coworkers, or friends who can attest to observing your functional limitations and symptom severity.
  • You have the right to submit a private medical opinion (nexus letter or IMO) from an independent medical professional to supplement or rebut the C&P examiner's findings.
  • Under the PACT Act and AMA framework, you have the right to a Supplemental Claim with new and relevant evidence if your initial rating does not accurately reflect your disability level.
  • You have the right to ask the examiner to clarify or re-examine any finding you believe was inaccurately recorded before the exam concludes.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.