Thoracic Spine

The single most counterintuitive fact about a thoracic spine claim is that the VA does not rate the thoracic spine as its own thing. Under 38 CFR § 4.71a, the thoracic (mid-back) and lumbar (low-back) segments are rated together as one unit called the "thoracolumbar" spine. A purely thoracic condition gets evaluated on thoracolumbar range of motion under the General Rating Formula for Diseases and Injuries of the Spine. There is no separate scoring lane for the mid-back in isolation.

That structure trips up a lot of claims. A veteran with a thoracic strain or thoracic degenerative changes expects the examiner to measure how the mid-back moves and pain. The General Rating Formula does not work that way. It measures forward flexion and combined range of motion of the whole thoracolumbar segment, and the same numbers that drive a low-back rating drive a thoracic-only rating. If the C&P exam treats the thoracic spine as a freestanding joint and measures it in isolation, the rating is built on the wrong data.

This page covers the diagnostic codes that apply to a thoracic condition, principally DC 5237 (lumbosacral or cervical strain, which the formula applies to thoracolumbar strain) and DC 5242 (degenerative arthritis of the spine), under the broader DC 5235 to DC 5243 family. It walks through the thoracolumbar rating tiers, the range-of-motion measurements the examiner has to capture, the separate-rating rule for associated neurologic abnormalities, and the DeLuca and Sharp functional-loss framework. In Claim Raven's analysis of 506 BVA thoracic spine cases, the C&P exam being inadequate is the single most common reason these claims stall, and the regulatory structure is a big part of why.

TL;DR

• The VA does not rate the thoracic spine in isolation. Under 38 CFR § 4.71a, the thoracic and lumbar segments are rated together as the "thoracolumbar" spine under the General Rating Formula. This is the key, counterintuitive point.
• A thoracic-only condition is scored on thoracolumbar forward flexion and combined range of motion, the same measurements that drive a low-back rating.
• Common codes: DC 5237 (lumbosacral or cervical strain, applied to thoracolumbar strain), DC 5242 (degenerative arthritis of the spine), within the DC 5235 to DC 5243 family.
• The thoracolumbar tiers run 10%, 20%, 40%, with 50% for unfavorable ankylosis of the entire thoracolumbar spine and 100% for unfavorable ankylosis of the entire spine.
• Note (1) of the formula requires associated objective neurologic abnormalities (radiculopathy, bowel, bladder) to be rated separately, which is where additional rating points live.
• DeLuca v. Brown and Sharp v. Shulkin apply: the rater has to account for functional loss during flare-ups, and 38 CFR § 4.59 brings painful motion into the analysis.
• In Claim Raven's analysis of 506 BVA thoracic spine cases, 134 were granted (26.5%), 132 remanded (26.1%), and 229 denied (45.3%). Of 410 cases with a C&P adequacy determination, 41.2% had the exam flagged as inadequate.
• The dataset codes overall outcome rather than a per-diagnostic-code breakdown, so I cannot read a DC 5237 versus DC 5242 split directly from it.

Why the Thoracic Spine Is Rated With the Lumbar Spine

The General Rating Formula for Diseases and Injuries of the Spine in 38 CFR § 4.71a divides the spine into two rating segments, not three. One segment is cervical (the neck). The other is thoracolumbar, which combines the thoracic and lumbar portions into a single unit. There is no standalone thoracic segment to rate.

This is a regulatory design choice, and it has a clinical logic behind it. The thoracic spine is the least mobile part of the back. The rib cage attaches to it and limits how much it can flex, extend, and rotate on its own. Most functional spinal motion in the mid-to-low back comes from the lumbar segment. So the formula folds the thoracic vertebrae into the thoracolumbar measurement rather than asking an examiner to isolate a few degrees of mid-back motion that the ribs already constrain.

The practical consequence: when you file for a thoracic condition, the rating is built on the same range-of-motion math as a lumbar claim. Forward flexion of the thoracolumbar spine, combined range of motion of the thoracolumbar spine, muscle spasm, guarding, and abnormal spinal contour are what the rater scores. A thoracic strain (DC 5237) and thoracic degenerative arthritis (DC 5242) both run through the General Rating Formula, and both are measured on the whole thoracolumbar segment.

If your mid-back condition coexists with a low-back condition, that does not produce two separate spine ratings for the same segment. Pyramiding under 38 CFR § 4.14 blocks rating the same thoracolumbar segment twice. The thoracic and lumbar findings combine into one thoracolumbar evaluation. What can be rated separately are neurologic abnormalities, which I cover below.

The Diagnostic Codes That Apply to a Thoracic Claim

The spine codes run from DC 5235 to DC 5243. A thoracic claim almost always lands on one of a small number of them, and they are nearly all rated under the same General Rating Formula. The diagnostic code is mostly a label for the underlying pathology. The rating tiers are shared.

DC 5237, Lumbosacral or cervical strain. Despite the name, this is the code the formula uses for thoracolumbar strain. A soft-tissue mid-back strain without a more specific structural diagnosis usually rates here, on thoracolumbar range of motion.

DC 5242, Degenerative arthritis of the spine. Degenerative changes in the thoracic vertebrae rate here. DC 5242 is evaluated either under the General Rating Formula (range of motion) or, where it produces incapacitating episodes from disc disease, by cross-reference, with the higher evaluation applied. Degenerative arthritis of the spine is also linked to DC 5003 for the X-ray and joint-involvement logic, but the spine formula governs once motion is measured.

The DC 5235 to DC 5243 family generally. This block covers vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), spinal stenosis (DC 5238), spondylolisthesis (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), and intervertebral disc syndrome (DC 5243). With the exception of the disc-syndrome incapacitating-episode method, all of them rate under the General Rating Formula on thoracolumbar motion and ankylosis.

The point that matters for a thoracic claim: the code chosen does not change the measurement. Whether the file calls it DC 5237 strain or DC 5242 arthritis, the rater is scoring thoracolumbar forward flexion, combined range of motion, and the spasm/guarding/contour findings. The diagnostic-code label is not where the rating swings. The measured motion is.

The Thoracolumbar Rating Tiers

The General Rating Formula assigns the same percentage tiers to the thoracolumbar segment that it assigns to the cervical segment, except the degree thresholds differ. For the thoracolumbar spine, these are the tiers:

40% Forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine 20% Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis 10% Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height

Above the 40% tier, the formula moves into ankylosis:

50% Unfavorable ankylosis of the entire thoracolumbar spine 100% Unfavorable ankylosis of the entire spine

Normal forward flexion of the thoracolumbar spine is 90 degrees. Normal combined range of motion (flexion plus extension plus left and right lateral flexion plus left and right rotation) is 240 degrees. The formula applies "with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease," which means pain does not have to be present for the motion-based rating to apply, and pain alone does not raise it past the measured tier without functional loss.

Two things stand out for a thoracic claimant. First, because the thoracic spine is naturally stiff, a thoracic-only condition often produces a relatively small reduction in thoracolumbar flexion, which can land at the 10% or 20% tier rather than the 40% tier. Second, the 20% "muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour" pathway does not require any specific flexion number. Documented spasm or guarding that produces an abnormal contour such as kyphosis can carry a 20% rating on its own. That alternative pathway is frequently undocumented in mid-back claims.

Note (1): Separate Ratings for Associated Neurologic Abnormalities

This is where additional rating points usually come from in a spine claim, and it is the part that gets dropped most often. Note (1) to the General Rating Formula states that any associated objective neurologic abnormalities are to be evaluated separately, under the appropriate diagnostic code.

The orthopedic rating (the thoracolumbar motion score) and the neurologic ratings are not the same impairment, so rating them separately does not violate pyramiding under 38 CFR § 4.14. A thoracic disc condition that produces radiating nerve symptoms can carry the thoracolumbar motion rating plus a separate rating for the radiculopathy. Bowel or bladder impairment associated with the spine condition is also rated separately under its own code.

Thoracic-level radiculopathy presents differently than lumbar radiculopathy. Instead of shooting pain down a leg, thoracic nerve-root involvement can produce a band-like or wrapping pain around the trunk along an intercostal distribution, chest-wall or abdominal-wall sensory changes, or numbness following a rib line. Because it does not look like classic sciatica, examiners and raters sometimes miss it. The separate neurologic rating only gets applied when the objective abnormality is documented: a specific nerve, a measurable sensory or motor deficit, and a link to the spine condition.

The pattern I see is that the orthopedic motion rating gets assigned and the neurologic question never gets developed. The exam does not include a focused neurologic assessment of the affected nerve distribution, so there is no objective finding for the rater to act on, so Note (1) goes unused. A complete claim documents the neurologic abnormality as its own line of evidence rather than assuming the motion rating captures it.

DeLuca, Sharp, and Functional Loss in a Stiff Segment

The functional-loss framework matters in spine claims the same way it matters in joint claims, and it interacts with the thoracic spine's natural stiffness in a specific way.

DeLuca v. Brown (1995) requires range-of-motion ratings to account for additional functional loss from pain, weakness, fatigability, or incoordination, not just the static measurement taken in the exam room. 38 CFR § 4.59 reinforces that painful motion is itself a form of functional loss that has to be considered. Sharp v. Shulkin (2017) requires the C&P examiner, when the veteran reports flare-ups, to estimate the additional functional loss during a flare in terms of degrees of lost motion, or to explain why an estimate is not feasible. The examiner cannot stop at "no flare observed today."

For a thoracic claim, this plays out around the flexion thresholds. Measured thoracolumbar flexion on the day of the exam might be 70 degrees, which sits at the 10% tier. But the veteran reports that during flare-ups the mid-back locks up, flexion drops sharply, and bending or twisting becomes impossible for days. Under DeLuca, § 4.59, and Sharp, the rater is supposed to consider the flare presentation, and a flare that pulls effective flexion down toward 30 to 60 degrees supports the 20% tier rather than the 10% tier.

In practice the flare layer falls out. The DBQ asks about flare-ups, the examiner writes "veteran reports occasional flare-ups" without a degree estimate, and the rater scores off the in-clinic number. The Board sends these back. A typical remand instruction reads:

"The Board finds the prior VA examination inadequate because the examiner did not estimate the Veteran's additional functional loss during flare-ups despite the Veteran's reports of flare-ups affecting the thoracolumbar spine. On remand, the examiner must address the flare-up question consistent with Sharp v. Shulkin and 38 C.F.R. § 4.59."

The evidence that supports a Sharp analysis comes from the veteran's own documentation: a symptom journal tracking which days the mid-back flares and what it stops you from doing, work-absence records, and lay statements from people who see you on bad days.

C&P Exam Mechanics: What the Examiner Has to Measure

The spine C&P exam follows the back (thoracolumbar) conditions DBQ. The measurements are not optional, and a thoracic claim lives or dies on whether they were taken correctly.

• Forward flexion of the thoracolumbar spine, with a goniometer, in degrees
• Extension, left and right lateral flexion, and left and right rotation, each measured, so combined range of motion can be calculated
• Repetitive-use testing (three repetitions) with re-measurement
• The point in the arc where pain begins
• A flare-up estimate with quantified functional loss where feasible, under Sharp
• Muscle spasm, guarding, and localized tenderness, and whether they produce abnormal gait or abnormal spinal contour
• A focused neurologic assessment of any affected nerve distribution, for the Note (1) separate rating

The most common and most damaging error in a thoracic claim is the examiner measuring the thoracic spine in isolation, or describing thoracic motion qualitatively, instead of recording thoracolumbar forward flexion and combined range of motion under the General Rating Formula. The formula has no input for isolated thoracic degrees. If the report does not contain thoracolumbar flexion and the other planes of motion, the rater does not have the data the rating tiers require, and the case is built to be remanded.

In Claim Raven's analysis of the 506 thoracic cases, of the 410 with a C&P adequacy determination, 41.2% had the exam flagged as inadequate. That is a high rate, and the structural mismatch between how veterans think about a mid-back condition and how the formula actually scores it is a plausible driver.

Secondary Chains and Co-Located Spine Conditions

A thoracic condition connects to other conditions in two distinct ways, and it is worth keeping them separate because they are rated differently.

The first is the co-located spine picture. Because the thoracic and lumbar segments share one thoracolumbar rating, a low-back condition does not stack on top of a thoracic condition for the same segment. They merge into one thoracolumbar evaluation. A cervical (neck) condition, by contrast, is a different rating segment and is rated separately under its own General Rating Formula application. So a veteran with both neck and mid-back conditions has two spine ratings (cervical plus thoracolumbar), while a veteran with both mid-back and low-back conditions has one (thoracolumbar).

The second is the secondary chain under 38 CFR § 3.310, which allows service connection for a condition caused or aggravated by a service-connected condition (Allen v. Brown). The chains that involve the thoracic spine include:

Posture and altered mechanics to other spine segments. A thoracic condition that changes how you hold yourself, or forces compensatory posture, can contribute to cervical or lumbar strain over time. The nexus opinion has to explain the mechanism and time course, not just assert proximity.

Thoracic disc disease to radiculopathy. As covered under Note (1), nerve-root involvement at a thoracic level is itself rated separately rather than as a secondary claim, but it has to be developed as objective neurologic evidence.

Pain and deconditioning to secondary conditions. Chronic mid-back pain that limits activity is sometimes argued as a contributor to weight gain, deconditioning, or a mental-health condition, though these arguments rise and fall entirely on the quality of the medical opinion.

For any of these, the standard is the same one that governs every secondary claim. A bare "this is secondary to that" without rationale is not probative. A factually accurate, fully articulated opinion that identifies the mechanism, addresses the time course, and rules out other causes carries the case.

Common Evidence Gaps in Thoracic Spine Claims

A few patterns I see across BVA decisions involving thoracic spine conditions.

The exam measures the wrong thing. The single biggest gap. The examiner treats the thoracic spine as an isolated joint and records thoracic motion, or describes the mid-back qualitatively, instead of recording thoracolumbar forward flexion and combined range of motion under the General Rating Formula. The rater then has no input the rating tiers can use. This is the structural trap unique to thoracic claims.

No flare-up estimate. The same Sharp problem that recurs in every musculoskeletal claim. The DBQ flags flare-ups, the examiner does not quantify them in degrees, and the functional-loss layer that could move a 10% rating to 20% never reaches the rating decision.

The neurologic question is never developed. Note (1) lets associated radiculopathy and bowel or bladder impairment be rated separately, but only on objective findings. Thoracic-level nerve involvement presents as band-like trunk pain or chest-wall sensory change rather than classic sciatica, so it gets overlooked. Without a focused neurologic exam, the separate rating goes unused.

Spasm and contour findings are not recorded. The 20% tier can be reached through muscle spasm or guarding severe enough to produce abnormal gait or abnormal spinal contour, with no specific flexion number required. If the exam does not document spasm, guarding, and contour (kyphosis, scoliosis, reversed lordosis), that alternative pathway to 20% is unavailable.

Imaging and diagnosis stay vague. A mid-back complaint logged in primary care as "thoracic pain" without imaging or a specific diagnosis tends to default to a minimal strain rating. X-ray shows bone; it does not show disc or soft-tissue pathology. Without the imaging that supports DC 5242 degenerative arthritis or disc syndrome, the structural basis for a higher rating is missing.

I do not know exactly what share of thoracic claims carry one or more of these gaps. What I can say from Claim Raven's analysis of 506 BVA thoracic spine cases is that 134 were granted (26.5%), 132 remanded (26.1%), and 229 denied (45.3%), and that of the 410 cases with a C&P adequacy determination, 41.2% had the exam flagged as inadequate. The denial share here is higher than the grant share, and the inadequate-exam rate is substantial. That pattern is consistent with the evidence-gap dynamics above: when the exam measures the wrong thing or skips the flare and neurologic questions, the record often cannot support the rating the veteran is seeking, and the case either gets denied or sent back for development.

What to Push For

A thoracic claim is won on getting the right measurements into the file. Three things move it.

First, make sure the exam scores the thoracolumbar segment, not the thoracic spine in isolation. The General Rating Formula needs thoracolumbar forward flexion and combined range of motion. An evidence checklist for spine claims should put thoracolumbar flexion, the other planes of motion, spasm and contour findings, and the neurologic assessment into their own proof lanes so nothing gets skipped.

Second, document flare-ups before the exam. A flare log with dates, what the mid-back stops you from doing on bad days, missed work, and any reduction in motion gives the examiner the facts a Sharp estimate requires. Use C&P exam prep for the thoracolumbar DBQ and track thoracic flare-ups and bad days ahead of time.

Third, develop the neurologic question separately. If you have band-like trunk pain, chest-wall numbness, or any radiating symptoms, ask for a focused neurologic assessment so a Note (1) separate rating has objective findings to rest on. Review the secondary conditions tool for the radiculopathy and posture chains.

Bottom Line

A thoracic spine rating is not a mid-back rating. It is a thoracolumbar rating, scored on forward flexion and combined range of motion of the whole lower-and-mid-back segment under the General Rating Formula in 38 CFR § 4.71a. The diagnostic-code label (DC 5237 strain, DC 5242 arthritis) does not change the measurement. The motion does. Most thoracic claims I have looked at stall in one of two ways: the exam measures the thoracic spine in isolation instead of the thoracolumbar segment, or it skips the flare-up estimate and the neurologic assessment that Note (1) and Sharp require. The cases that succeed have a complete thoracolumbar exam, a documented flare history, and any associated neurologic abnormality developed as its own line of evidence. Same condition, different paper trail, different outcome.

Related Conditions

Thoracic spine claims share rating logic and proof issues with the rest of the spine. They connect most directly to back and cervical spine claims, since all three run through the spine formulas, and to degenerative disc disease, herniated disc, spinal stenosis, and scoliosis where the underlying pathology overlaps. Veterans with mid-back and low-back conditions should remember those merge into one thoracolumbar rating, while a neck condition rates separately, and should review the secondary conditions tool before assuming a single spine rating tells the whole story.

Methodology and Limitations

• Data source: Rating criteria quoted from 38 CFR § 4.71a, the General Rating Formula for Diseases and Injuries of the Spine, DCs 5235 through 5243, principally DC 5237 and DC 5242. Pyramiding from § 4.14. Painful motion from § 4.59. Separate neurologic ratings from Note (1) of the General Rating Formula. Secondary service connection from § 3.310. Case law from DeLuca v. Brown, Sharp v. Shulkin, and Allen v. Brown.
• Sample size: Patterns in this post are drawn from Claim Raven's analysis of 101,518 condition records drawn from the analyzed subset of Claim Raven's 501,000+ Board-decision library, including 506 thoracic spine cases. Within that subset, outcomes ran 134 granted (26.5%), 132 remanded (26.1%), and 229 denied (45.3%). Of the 410 cases that carried a C&P adequacy determination, 41.2% had the exam flagged as inadequate. The dataset captures overall outcome rather than a per-diagnostic-code (DC 5237 versus DC 5242) breakdown.
• Classification approach: Diagnostic code definitions and rating tiers drawn from the regulatory text. The thoracolumbar-segment structure follows the General Rating Formula as written.
• Limitations:
• Rating tiers and degree thresholds are quoted from the General Rating Formula. The formula text is periodically amended, so confirm the current version of § 4.71a for any active claim.
• The thoracic spine has no isolated rating segment; all figures here reflect thoracolumbar measurement, which is the regulatory design.
• Selection bias: BVA-level patterns reflect cases that appealed. Most thoracic spine claims resolve at the RO level and are not in any BVA dataset.
• Application of the Sharp v. Shulkin and § 4.59 functional-loss framework at the RO level is uneven.
• The percentages reported are the real outcome counts for the 506-case subset and the 410-case adequacy subset. No other claim-level statistics here are quantified; qualitative observations are labeled as such.
• These observations reflect patterns from the regulatory text, case law, and BVA decisions. They are not predictions of individual outcomes.