C&P Exam for Vertebral fracture or dislocation (DC 5235)

Diagnostic code: 5235Condition: Vertebral fracture or dislocationRegulation: 38 CFR § 4.71aDBQ: DBQ MUSC Back (Thoracolumbar Spine); DBQ MUSC Neck (Cervical Spine)

Which form the examiner uses

For vertebral fracture or dislocation (DC 5235), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

DBQ MUSC Back (Thoracolumbar Spine)

This DBQ evaluates thoracolumbar spine conditions including range of motion, muscle strength, neurologic findings, ankylosis, and IVDS.

How DC 5235 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-X and XIV-XVII of this form. Sections III and IX are the condition-specific sections for this code. Sections XI-XIII cover unrelated conditions on this DBQ and are skipped.

DIAGNOSIS (Section I)
  • 1A. List the claimed condition(s) that pertain to this questionnaire:
  • 1B. Select diagnoses associated with the claimed condition(s) (check all that apply): The Veteran does not have a current diagnosis associated with any claimed conditions listed above.
  • Ankylosing spondylitis - ICD Code / Date of diagnosis
  • Degenerative arthritis - ICD Code / Date of diagnosis
  • Degenerative disc disease other than intervertebral disc syndrome (IVDS) - ICD Code / Date of diagnosis
  • Lumbosacral strain - ICD Code / Date of diagnosis
  • Intervertebral disc syndrome - ICD Code / Date of diagnosis
  • Sacroiliac injury - ICD Code / Date of diagnosis
  • Sacroiliac weakness - ICD Code / Date of diagnosis
  • Segmental instability - ICD Code / Date of diagnosis
  • Spinal fusion - ICD Code / Date of diagnosis
  • Spinal stenosis - ICD Code / Date of diagnosis
  • Spondylolisthesis - ICD Code / Date of diagnosis
  • Traumatic paralysis, complete - ICD Code / Date of diagnosis
  • Vertebral dislocation - ICD Code / Date of diagnosis
  • Vertebral fracture - ICD Code / Date of diagnosis
  • Other diagnosis #1 - ICD Code / Date of diagnosis
  • Other diagnosis #2 - ICD Code / Date of diagnosis
  • Other diagnosis #3 - ICD Code / Date of diagnosis
  • 1C. If there are additional diagnoses pertaining to thoracolumbar spine conditions, list using above format:
MEDICAL HISTORY (Section II)
  • 2A. Describe the history (including onset and course) of the Veteran's thoracolumbar spine condition (brief summary):
  • 2B. Does the Veteran report flare-ups of the thoracolumbar spine?
  • If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity, and/or extent of functional impairment he/she experiences during a flare-up of symptoms:
  • 2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after repeated use over time?
  • If yes, document the Veteran's description of functional loss or functional impairment in his/her own words.
RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATION (Section III)
  • 3A. Initial ROM measurements: All Normal / Abnormal or outside of normal range / Unable to test / Not indicated
  • If ROM is outside of 'normal' range, but is normal for the Veteran (for reasons other than a back condition, such as age, body habitus, neurologic disease), please describe:
  • If abnormal, does the range of motion itself contribute to a functional loss?
  • Can testing be performed?
  • Active ROM - Forward flexion endpoint (90 degrees): degrees
  • Active ROM - Extension endpoint (30 degrees): degrees
  • Active ROM - Right lateral flexion endpoint (30 degrees): degrees
  • Active ROM - Left lateral flexion endpoint (30 degrees): degrees
  • Active ROM - Right lateral rotation endpoint (30 degrees): degrees
  • Active ROM - Left lateral rotation endpoint (30 degrees): degrees
  • If noted on examination, which ROM exhibited pain (select all that apply): Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation
  • If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically attributable to the factors identified and describe. [Active - Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation degree endpoints]
  • Was passive range of motion testing performed?
  • Passive ROM - Forward flexion endpoint (90 degrees): degrees / Same as active ROM
  • Passive ROM - Extension endpoint (30 degrees): degrees / Same as active ROM
  • Passive ROM - Right lateral flexion endpoint (30 degrees): degrees / Same as active ROM
  • Passive ROM - Left lateral flexion endpoint (30 degrees): degrees / Same as active ROM
  • Passive ROM - Right lateral rotation endpoint (30 degrees): degrees / Same as active ROM
  • Passive ROM - Left lateral endpoint (30 degrees): degrees / Same as active ROM
  • If noted on examination, which passive ROM exhibited pain (select all that apply): Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation
  • If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) [Passive - Forward flexion / Extension / Right lateral flexion / Left lateral flexion / Right lateral rotation / Left lateral rotation degree endpoints]
  • Is there evidence of pain? If yes check all that apply: Weight-bearing / Nonweight-bearing / Active motion / Passive motion / On rest/non-movement / Causes functional loss / Does not result in/cause functional loss
  • Is there objective evidence of crepitus?
  • Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue?
  • If yes, describe location, severity, and relationship to condition(s):
  • 3B. Is the Veteran able to perform repetitive use testing with at least three repetitions?
  • Is there additional loss of function or range of motion after three repetitions?
  • After three repetitions - Forward flexion endpoint (90 degrees): degrees
  • After three repetitions - Extension endpoint (30 degrees): degrees
  • After three repetitions - Right lateral flexion endpoint (30 degrees): degrees
  • After three repetitions - Left lateral flexion endpoint (30 degrees): degrees
  • After three repetitions - Right lateral rotation endpoint (30 degrees): degrees
  • After three repetitions - Left lateral rotation endpoint (30 degrees): degrees
  • Select all factors that cause this functional loss: (check all that apply) N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
  • 3C. Is the Veteran being examined immediately after repeated use over time?
  • Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?
  • Select all factors that cause this functional loss [repeated use]: N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
  • Estimated ROM immediately after repeated use over time - Forward flexion endpoint (90 degrees): degrees
  • Estimated ROM immediately after repeated use over time - Extension endpoint (30 degrees): degrees
  • Estimated ROM immediately after repeated use over time - Right lateral flexion endpoint (30 degrees): degrees
  • Estimated ROM immediately after repeated use over time - Left lateral flexion endpoint (30 degrees): degrees
  • Estimated ROM immediately after repeated use over time - Right lateral rotation endpoint (30 degrees): degrees
  • Estimated ROM immediately after repeated use over time - Left lateral rotation endpoint (30 degrees): degrees
  • Please cite and discuss evidence [repeated use over time]. (Must be specific to the case and based on all procurable evidence):
  • 3D. Is the Veteran being examined during a flare-up?
  • Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups?
  • Select all factors that cause this functional loss [flare-ups]: N/A / Pain / Fatigability / Weakness / Lack of endurance / Incoordination / Other
  • Estimated ROM during flare-ups - Forward flexion endpoint (90 degrees): degrees
  • Estimated ROM during flare-ups - Extension endpoint (30 degrees): degrees
  • Estimated ROM during flare-ups - Right lateral flexion endpoint (30 degrees): degrees
  • Estimated ROM during flare-ups - Left lateral flexion endpoint (30 degrees): degrees
  • Estimated ROM during flare-ups - Right lateral rotation endpoint (30 degrees): degrees
  • Estimated ROM during flare-ups - Left lateral rotation endpoint (30 degrees): degrees
  • Please cite and discuss evidence [flare-ups]. (Must be specific to the case and based on all procurable evidence):
  • 3E. Does the Veteran have localized tenderness, guarding or muscle spasm of the thoracolumbar spine?
  • Localized tenderness: None / Not resulting in abnormal gait or abnormal spinal contour
  • Muscle spasm: None / Resulting in abnormal gait or abnormal spine contour / Not resulting in abnormal gait or abnormal spinal contour / Unable to evaluate
  • Guarding: None / Resulting in abnormal gait or abnormal spine contour / Not resulting in abnormal gait or abnormal spinal contour / Unable to evaluate
  • 3F. In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: None / Interference with sitting / Interference with standing / Swelling / Deformity / Disturbance of locomotion / Less movement than normal / More movement than normal / Weakened movement / Atrophy of disuse / Instability of station / Other
  • Please describe additional contributing factors of disability:
MUSCLE STRENGTH TESTING (Section IV)
  • 4A. Right Hip Flexion strength (/5)
  • 4A. Right Knee Extension strength (/5)
  • 4A. Right Ankle Plantar Flexion strength (/5)
  • 4A. Right Ankle Dorsiflexion strength (/5)
  • 4A. Right Great Toe Extension strength (/5)
  • 4A. Left Hip Flexion strength (/5)
  • 4A. Left Knee Extension strength (/5)
  • 4A. Left Ankle Plantar Flexion strength (/5)
  • 4A. Left Ankle Dorsiflexion strength (/5)
  • 4A. Left Great Toe Extension strength (/5)
  • 4B. Does the Veteran have muscle atrophy?
  • 4C. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section?
  • 4D. Circumference of normal side: cm
  • 4D. Circumference of atrophied side: cm
REFLEX EXAM (Section V)
  • 5A. Right Knee deep tendon reflex (+)
  • 5A. Right Ankle deep tendon reflex (+)
  • 5A. Left Knee deep tendon reflex (+)
  • 5A. Left Ankle deep tendon reflex (+)
SENSORY EXAM (Section VI)
  • 6A. Right Upper Anterior Thigh (L2): Normal / Decreased / Absent
  • 6A. Right Thigh/Knee (L3/4): Normal / Decreased / Absent
  • 6A. Right Lower Leg/Ankle (L4/L5/S1): Normal / Decreased / Absent
  • 6A. Right Foot/Toes (L5): Normal / Decreased / Absent
  • 6A. Left Upper Anterior Thigh (L2): Normal / Decreased / Absent
  • 6A. Left Thigh/Knee (L3/4): Normal / Decreased / Absent
  • 6A. Left Lower Leg/Ankle (L4/L5/S1): Normal / Decreased / Absent
  • 6A. Left Foot/Toes (L5): Normal / Decreased / Absent
  • Other sensory findings, if any:
STRAIGHT LEG RAISING TEST (Section VII)
  • 7A. Right straight leg raising test: Negative / Positive / Unable to perform
  • 7A. Left straight leg raising test: Negative / Positive / Unable to perform
  • If 'Unable to perform,' please explain:
RADICULOPATHY (Section VIII)
  • Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
  • 8A. Constant pain (may be excruciating at times): Right lower extremity: None / Mild / Moderate / Severe
  • 8A. Constant pain (may be excruciating at times): Left lower extremity: None / Mild / Moderate / Severe
  • 8A. Intermittent pain (usually dull): Right lower extremity: None / Mild / Moderate / Severe
  • 8A. Intermittent pain (usually dull): Left lower extremity: None / Mild / Moderate / Severe
  • 8A. Paresthesias and/or dysesthesias: Right lower extremity: None / Mild / Moderate / Severe
  • 8A. Paresthesias and/or dysesthesias: Left lower extremity: None / Mild / Moderate / Severe
  • 8A. Numbness: Right lower extremity: None / Mild / Moderate / Severe
  • 8A. Numbness: Left lower extremity: None / Mild / Moderate / Severe
  • 8B. Does the Veteran have any other signs or symptoms of radiculopathy?
  • 8C. Involvement of L2/L3/L4 nerve roots (femoral nerve): Right / Left / Both
  • 8C. Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve): Right / Left / Both
  • 8C. Other nerves (specify nerve and side(s) affected): Right / Left / Both
  • 8D. For any abnormal or positive identified neurological findings identified in Sections 4-8, explain the likely cause of those identified symptoms:
ANKYLOSIS (Section IX)
  • 9A. Is there ankylosis of the spine?
  • If yes, indicate severity of ankylosis: Unfavorable ankylosis of the entire spine / Unfavorable ankylosis of the entire thoracolumbar spine / Favorable ankylosis of the entire thoracolumbar spine
  • 9B. Comments, if any:
OTHER NEUROLOGIC ABNORMALITIES (Section X)
  • 10A. Does the Veteran have any other neurologic abnormalities or findings (other than those identified in Sections 4 - 8) related to a thoracolumbar spine condition (such as bowel or bladder problems/pathologic reflexes)?
  • If yes, describe condition and how it is related:
INTERVERTEBRAL DISC SYNDROME (IVDS) AND EPISODES REQUIRING BED REST (Section XI)
  • 11A. Does the Veteran have IVDS of the thoracolumbar spine?
  • 11B. Has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months?
  • If yes, select the total duration over the past 12 months: With no episodes of bed rest / At least 1 week but less than 2 weeks / At least 2 weeks but less than 4 weeks / At least 4 weeks but less than 6 weeks / At least 6 weeks
  • 11C. Medical history as described by the Veteran only, without documentation:
  • 11C. Medical history as shown and documented in the Veteran's file - Individual date(s) of each treatment record(s) reviewed:
  • 11C. Facility/provider:
  • 11C. Describe treatment:
ASSISTIVE DEVICES (Section XII)
  • 12A. Does the Veteran use any assistive devices as a normal mode of locomotion?
  • Wheelchair - Frequency of use: Occasional / Regular / Constant
  • Brace(s) - Frequency of use: Occasional / Regular / Constant
  • Crutch(es) - Frequency of use: Occasional / Regular / Constant
  • Cane(s) - Frequency of use: Occasional / Regular / Constant
  • Walker - Frequency of use: Occasional / Regular / Constant
  • Other - Frequency of use: Occasional / Regular / Constant
  • 12B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.
REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section XIII)
  • 13A. Due to the Veteran's thoracolumbar spine condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis?
  • If yes, indicate extremities for which this applies: Right lower / Left lower / Right upper / Left upper
  • For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):
OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section XIV)
  • 14A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above?
  • If yes, describe (brief summary):
  • 14B. Does the Veteran have any scars or other disfigurement of the skin related to any conditions or to the treatment of any conditions listed in the diagnosis section?
  • 14C. Comments, if any:
DIAGNOSTIC TESTING (Section XV)
  • 15A. Have imaging studies been performed in conjunction with this examination?
  • 15B. If yes, is degenerative or post-traumatic arthritis documented?
  • 15C. If yes, provide type of test or procedure, date and results (brief summary):
  • 15D. Does the Veteran have imaging evidence of a thoracolumbar vertebral fracture?
  • If yes, is there loss of 50 percent or more of height?
  • 15E. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with this examination?
  • If yes, provide type of test or procedure, date and results (brief summary):
  • 15F. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:
FUNCTIONAL IMPACT (Section XVI)
  • 16A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting etc.)?
  • If yes, describe the functional impact of each condition, providing one or more examples:
REMARKS (Section XVII)
  • 17A. Remarks (if any – please identify the section to which the remark pertains when appropriate).

Rating Levels for DC 5235

The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

What the Board discussed in granted decisions for DC 5235

The themes below were extracted by clustering 500 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

  1. 32% Benefit of doubt doctrine stated or applied generally
    The Board cited, acknowledged, or applied the statutory benefit of the doubt doctrine, noting that approximate balance of positive and negative evidence requires resolving the matter in the claimant's favor.
    162 of 500 sample sentences
  2. 21% Preponderance against claim; benefit of doubt inapplicable
    The Board determined that the weight of evidence preponderantly favored denial, making the benefit of the doubt doctrine inapplicable and the claim denied.
    104 of 500 sample sentences
  3. 18% Evidence in equipoise warranting grant of claim
    The Board found the evidence for and against the claim was in relative equipoise or approximate balance, and accordingly granted the rating, service connection, or effective date at issue.
    89 of 500 sample sentences
  4. 13% Medical nexus opinion citing at-least-as-likely standard
    A VA or private examiner recorded an opinion that a current disability was at least as likely as not caused by, related to, or aggravated by service or a service-connected condition.
    64 of 500 sample sentences
  5. 9% Benefit of doubt applied to assign specific disability rating
    The Board resolved doubt in the Veteran's favor and assigned a specific schedular percentage rating, finding the evidence supported that evaluation under the applicable diagnostic code.
    47 of 500 sample sentences
  6. 4% Benefit of doubt applied to grant service connection
    The Board extended the benefit of the doubt to the Veteran and found the evidence sufficient to establish service connection for a specific disability.
    18 of 500 sample sentences
  7. 2% Benefit of doubt applied to TDIU or unemployability finding
    The Board resolved reasonable doubt in the Veteran's favor and found that service-connected disabilities rendered the Veteran unable to secure or follow substantially gainful employment.
    9 of 500 sample sentences
  8. 1% Examiner opinion on nexus or rating noted as unfavorable
    An examiner recorded an opinion that a disability was not related to service, not at least as likely as not linked to a service-connected condition, or did not meet rating criteria, weighing against the claim.
    7 of 500 sample sentences
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Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.