CHIEF COMPLAINT: Michael is a 61-year-old man referred for medical evaluation.

HISTORY: This middle-aged man was well until over four years ago when he claims he was injured seriously at work. A roughly 600-pound piece of equipment began to fall, and in attempting to stop it from doing so, he developed acute low back pain. This was treated by Dr. Jones. Although much improved compared to before the surgery, he continues to have pain and other problems at this time.

Prior to this accident, he had never undergone lumbar imaging. He had never been to a healthcare provider for back problems. The pain began to hurt immediately, and has gotten better over time (with the surgery of Dr. Jones). The pain is primarily axial in the back, though it travels down both hips and then diffusely into the thighs, legs, and feet. The majority of the pain is axial and to the right side of the midline. The pain is constant, and is both moderate-to-severe. He has no comfortable position. It hurts both at rest and with activity, but is worse with activity.

He has undergone physical therapy that was somewhat helpful. He has not been to a chiropractor. He has undergone no spinal injections. He currently takes both tramadol and oxycodone for discomfort.

He was out of work for about two years, but has currently returned. He is not capable of physically demanding activity due to his back discomfort. He is independent at home and can drive a car, though he fails for longer distances.

I asked him about his hip pain, and he says that the right hurts more than his left. He was very clear that the hip pain did not start until two years after the 2013 accident (sometime in 2015). This pain hurts at all times, and he has no comfortable position.

He is currently back working in a carpentry setting. He no longer does the heavy physical labor, but does supervisory work.

He takes less than one narcotic tablet per day, and estimates 2 hydrocodone or 2 oxycodone tablets a week. He takes daily tramadol.

OCCUPATION: Carpenter.

PERSONAL HISTORY: He is married, and has three children.

FAMILY HISTORY: His parents are both deceased.

DRUG ALLERGIES: None.

HABITS: He neither drinks nor smokes.

CURRENT MEDICATIONS: Tramadol and oxycodone.

REVIEW OF SYSTEMS: Poor exercise tolerance, painful joints, neck pain, back pain, poor muscle strength, arm weakness, leg weakness. The patient denied high blood pressure, arthritis, abdominal pain, abdominal swelling, black, tarry bowel movements; change in bowel habits, constipation, cirrhosis of the liver, cramps, diarrhea, gallstones, heartburn, hemorrhoids, hepatitis, indigestion, nausea, passing of blood from rectum, stomach or duodenal ulcer, vomiting, vomiting of blood. EARS: The patient denied drainage from ear, ear pain, or sinus trouble. GENITOURINARY: The patient denied blood in urine, difficulty controlling urine, difficulty passing urine, kidney stones, pain or burning while urinating. NEUROLOGICAL: The patient denied blurred vision, buzzing, or ringing in ears, difficulty with balance, difficulty with hearing or deafness, difficulty swallowing, dizzy spells, double vision, fainting spells, light flashes, memory loss, persistent hoarseness, severe headaches, speech difficulty, or stiffness. SKIN: The patient denied changing or bleeding moles, or rash. NECK: The patient denied neck stiffness, or new unexplained lumps. BONES & JOINTS: The patient denied polio, rheumatic fever, or swollen joints. CHEST, HEART, LUNGS: The patient denied abnormal chest x-ray, abnormal electrocardiogram, chest pain, enlarged heart, angina, coughing up blood, fluttering of the heart, frequent cough, heart attack, heart murmur as an adult, shortness of breath, unusual heartbeat, varicose veins, wheezing. ENDOCRINE: The patient denied coldness most of the time, diabetes, goiter, gout, night sweats, overactive thyroid, poor exercise tolerance, thirstiness, underactive thyroid, unusual fatigue or sluggishness, unusual jumpiness or nervousness, or warmness most of the time. PSYCHOLOGICAL PROBLEMS: The patient denied serious depression and made no mention of any serious psychiatric disorder. HEMATOLOGIC: The patient denied easy bruising, nosebleeds not due to injuries, poor blood clotting, swollen glands, unexplained fevers, chills.

PRIOR SURGICAL HISTORY: Back surgery in August 2013. ¹

EXAMINATION

CONSTITUTIONAL
He is an unusually pleasant and likeable man, who comes in by himself. Vital signs and measurements were: Height 6 feet 0 inches, weight 205 pounds, heart rate 80, respirations 16, blood pressure 130/72.

GENERAL MEDICAL ASSESSMENT:
Carotid artery examination revealed no evidence of bruit or other abnormality. Heart rhythm was normal without extra sounds or murmurs. There was no abnormality of the peripheral vascular system and the right radial pulse was strong. Breath sounds were clear without rales, rhonchi, or wheezes. The abdomen was soft and non-tender. No masses were palpated.

NEUROLOGICAL
Mental status exam was normal. Orientation was normal, and memory was intact. Attention span and concentration were normal. Receptive and expressive speech was normal. Fund of knowledge was normal.

Cranial nerve II: To confrontational testing, there was no peripheral field abnormality. Visual acuity was intact to reading small print.
Cranial nerve III, IV, VI: Extraocular movements are full without nystagmus.
Cranial nerve V: Facial sensation is symmetric.
Cranial nerve VII: Facial movement is symmetric.
Cranial nerve VIII: Hearing is symmetric.
Cranial nerve IX, X: Palate elevates in the midline.
Cranial nerve XI: Shoulder shrug is strong bilaterally.
Cranial nerve XII: Tongue is midline.

Motor exam of the limbs was intact. There was full power and tone, and no fasciculations or abnormal movements were noted.

UPPER LIMBS: Deltoid power (C5) was 5/5 bilaterally, brachioradialis power (C5, 6) was 5/5 bilaterally, biceps power (C6) was 5/5 bilaterally, triceps power (C7) was 5/5 bilaterally, long finger flexors (C8) were 5/5 bilaterally, and hand intrinsics (C8, T1) power were 5/5 bilaterally.

LOWER LIMBS: Quadriceps power (L4) was 5/5 bilaterally, anterior tibialis (L4, 5) and extensor hallucis power (L5) were 5/5 bilaterally, and plantar flexion (S1) was normal bilaterally.

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¹ He gave me written and verbal permission to review any medical records that are obtainable online.

Sensory examination with a pinwheel was unremarkable with no focal deficit in a peripheral nerve or root distribution. Reflexes were normal and symmetric in the upper and lower limbs.

BACK
Examination of the neck was normal. When viewed from the side, the lordotic curve was normal. Range of motion was full. I carefully palpated and examined the lumbar musculature that consisted of the latissimi, quadratus lumborum, and multifidus muscles. There was no atrophy or fasciculation. There was no abnormality of muscle tension, and no spasm.

He had three of the five Waddell’s signs for the lumbar spine, namely, positive torso rotation test, positive press test, and excessive pain on examination of his lumbar spine.

Examination of his back showed parallel and linear well-healed scars.

PAIN DISABILITY QUESTIONNAIRE: 110.

OSWESTRY DISABILITY QUESTIONNAIRE: 35.

PATIENT NARRATIVE: Before leaving the office, a clipboard and a piece of paper were given with “Please write down everything you feel we should know about your accident and injuries from it.” I carefully reviewed what was written, and it did not add anything to either the record review or the narrative I took from the patient.

His only comment was why the numbness in his thighs was not checked.²

TIME IN OFFICE: Arrival at our office was at 1:37pm. He was seen immediately by our medical assistant, and then me, and left at 3:09 pm.

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² I checked those with a pinwheel.

PAIN DIAGRAM:

RECORD REVIEW:

On August 17, 2013, Mr. Smith claims he was injured seriously (subject accident).

On August 18, 2013, he underwent lumbosacral x-rays that showed a comminuted compression fracture of L4 with approximately 25% of loss of height and anterior displacement of an inferior fragment.

On August 18, 2013, he had pain that was acute. It was located in the lower back. It began about six days previously and became worse yesterday after lifting a coke machine. The pain radiated to the right upper thigh and the left upper thigh. “The problem was sustained six days ago when going upstairs he slipped and fell backwards landing on his back on a landing five steps back.” He was seen at Urgent Care Clinic where he complained of rib pain. The prior day he had lifted a coke machine and had the acute onset of more pain in his low back. Neurological review of systems was negative for numbness, tingling, and weakness. Detailed neurological examination was normal. His x-rays showed a compression fracture at L4. An MRI showed foraminal narrowing and abnormal signal in the soft tissues. The case was discussed with Dr. Jones.

On August 18, 2013, he underwent lumbosacral MRI at FH. There was mild central stenosis at L4-L5. There was compression fracture of L4 which had lost 25% of its height.

On August 18, 2013, he underwent LS x-rays at FH. There was a compression fracture at L4. Additional imaging with MR and CT was recommended.

On August 20, 2013, he underwent lumbosacral x-rays at FH. It was compared to an August 18, 2013, study which was of superior quality.

On August 18, 2013, he underwent an LS CT at FH. It showed a burst-type fracture of L4 with approximately 25% loss of height. There was mild stenosis at that level. There were fractures of the 10th and 11th ribs.

On August 18, 2013, he was seen. He is a 56-year-old man who had fallen six days previously on a flight of stairs landing on his back. He initially only had low back pain, but the prior day he was lifting a Coca-Cola machine at work and developed acute worsening of his low back pain. He was married with two children. He denied tobacco use and worked as a construction superintendent. Neurological examination was normal. Neurosurgery recommended admission for pain control and possible brae fitting.

On August 18, 2013, he underwent LS CT at FH that showed a L4 fracture.

On August 18, 2013, Dr. Coleman saw him in the FH ER. He was helping a coworker move a heavy piece of equipment when he had sudden onset of low back pain. He had no symptoms or paresthesias. There was no weakness in his legs. LS MR showed a L4 compression fracture with 25% loss of vertebral body height. Neurological examination was normal. He will be placed at bed rest and fitted with an orthotic device.

On August 27, 2013, he underwent a LS CT. There was a slight settling of L4 from 18 to 16 mm.

On August 27, 2013, Dr. Arns of the Neurosurgical Service did an initial consultation. He had been admitted on August 18, 2013, for an L4 burst fracture that was managed non-operatively with lumbosacral orthosis. He came in to the emergency room with worsened pain. He believed it occurred while moving a heavy object on August 17, 2013, and was unrelated to a fall days previously. He was on OxyContin for pain with increased leg weakness and numbness. He used a walker and complained of bilateral foot numbness. He denied saddle anesthesia or sphincter disturbance. Neurological examination was normal. He might be a candidate for operative intervention.

On August 28, 2013, Dr. Jones dictated an operative note. He describes him as a 56-year-old man, who had a burst fracture after a fall. This was managed conservatively initially with an orthotic brace. His pain significantly worsened in spite of narcotics. A follow-up scan showed diminished vertebral height. He had failed conservative measures, and neurosurgery was recommended.

On August 28, 2013, a CT shows interval L3 to L5 fusion with satisfactory hardware alignment. There was a 6-mm retropulsion with moderate stenosis.

On August 28, 2013, he underwent an evaluation during a neurosurgical consult by Dr. Risk, a Neurosurgery Resident. Neurological examination was normal.

On August 31, 2013, a pathology report from the bone showed no evidence of malignancy.

On September 9, 2013, Dr. Sam dictated a discharge history and physical. He had undergone an L3 to L5 PPS. He was discharged on several medications including oxycodone.

On October 2, 2013, a final physical therapy note describes his attending three visits. His diagnosis was a closed fracture without a spinal cord injury. He had undergone percutaneous pedicle screw placement.

On October 10, 2013, Dr. Jones saw him. His medical course is described in detail. A biopsy was taken and there was no evidence of tumor. The procedure had been done for internal stabilization of his spine that had been weakened by the burst fracture. In a year or two, the instrumentation might be removed. “At this time, the patient can go back to work.” He could transition to full duty and do not need a brace.

On November 22, 2013, he underwent a lumbosacral CT scan at FH. It showed an L3 to L5 fusion with intact hardware and satisfactory alignment. There was some slight loss of the L4 vertebral height.

On January 6, 2014, Dr. Jones saw him. He was four months out from L3 to L5 PPS. The pain was narcotic dependent and he took oxycodone. Neurological examination was normal. Ongoing conservative measures were recommended.

On March 12, 2014, Dr. Jones saw him. He was six months out from an L3 to L5 percutaneous pedicle screw stabilization (PPS). He was in physical therapy. He took Tylenol with Codeine. Neurological examination was normal. He was doing well and would continue with conservative measures.

On April 2, 2014, Dr. Jones saw him. He had undergone a L3 to L5 percutaneous pedicle screw stabilization for an L4 burst fracture. He had been undergoing physical therapy.

On May 24, 2014, Dr. Jones saw him. He had seen him many times since his L4 burst fracture and treated with L3 to L5 percutaneous pedicle screws. He was doing fairly well after surgery. He had pain and numbness in both of his feet and requested a disability letter and return to work. His date of birth was October 26, 1956. Dr. Jones stated, “at this point, I do not think I can do that. From the spine fracture and the surgery perspective, I think he has recovered and there should not be any strict limitations. The limitations maybe no strenuous activity, no heavy lifting for the back because subjectively the patient stated he has experiencing pain after physical therapy or any strenuous physical activity.” He stated that from the surgical perspective, he was doing well and there was no “strong limitation.” He then states “the patient feels his overall body pain and back pain is from his age and arthritis.” He will be seen on an as needed basis.

On August 15, 2014, he was seen in clinic. There was a question of a mild peripheral neuropathy. Repeat nerve studies were recommended. Dr. Mann performed electrodiagnostic studies.

On August 19, 2014, Dr. Pont saw him. He had undergone surgery for his L4 fracture. EDS showed normal motor function. He had reduced pin sensation in his legs. Conservative measures were recommended.

On February 1, 2015, he had gone back to work on a full-time basis. He had increased pain and limited endurance due to back discomfort. 15 tablets of Percocet per month would be allowed. Conservative measures were recommended.

On April 3, 2016, he had chronic low back pain and had not been seen for several months. “He has been doing fairly well with his full work schedule.” He had variation of pain throughout the day and used either tramadol or oxycodone on an as needed basis. The pain went across the back and to both the hips. He took one to two oxycodone tablets per week, and one to two tramadol tablets per day. Neurological examination was normal with intact sensation. The impression was chronic musculoskeletal pain. Conservative measures were recommended.

On August 4, 2017, a physiatrist, wrote a letter in regard to Mr. Smith. The patient complained of daily, but variable low back pain in association with bilateral leg, thigh, and hip pain. The right leg was worse than the left. A medical history is detailed including the accident and his subsequent treatment. He describes a March 2017 lumbosacral MRI that showed degenerative changes from L1 to L4. There was progression of degenerative change at L3-L4 with bilateral narrowing. He further describes a clinic visit on August 1, 2017, when he claimed that his right hip pain was getting worse. He had tenderness to palpation of the right hip adductors. He was married and working full time as a supervisor for a construction company. His exercise was limited. Neurological examination showed no focal weakness, though he had subjective numbness and tingling in his feet. His diagnoses were a prior fusion and degenerative lumbar changes. He additionally rendered the diagnosis of chronic hip and buttock musculoskeletal pain. He related all of these to the subject accident. He was not at a medical end result. There was evidence of progression of degenerative changes at L3-L4 and L5-S1. He might require narcotics to sustain his level of activity. He applied a 23% whole person impairment according to the fifth version of the American Medical Association Guidelines.³ His prognosis was indefinite and had chronic daily pain.

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³ I checked those with a pinwheel.

IMAGING: I reviewed the below imaging studies personally.

 

On August 18, 2013, he underwent a lumbosacral x-rays. It shows a compression fracture at L4. The alignment is normal.

 

On August 18, 2013, he underwent a lumbosacral MRI. The compression fracture seemed at L4 with normal alignment and increased signal on the STIR sequence. Spinal canal was widely patent.

 

On August 18, 2013, he underwent a lumbosacral CT scan in Boston. It shows the compression fracture at L4 with mild posterior retropulsion. The spinal canal was widely patent. Coronal views show no clinically significant translation.

 

On August 28, 2013, he underwent a pedicle screw fixation from L3 to L5. Instrumentation is in perfect position. Alignment is normal.

 

On November 22, 2013, he underwent a lumbosacral CT scan. It shows the instrumentation in excellent position. There has been no further progression of the compression fracture at L4. Alignment is normal.

 

In March 2017, he underwent a lumbosacral MRI. It shows a prior L2-4 fusion. Screws are in satisfactory position. Is no evidence of any left-sided canal or nerve compromise.

On August 18, 2013, he underwent a lumbosacral x-ray. It shows a moderate L4 compression fracture. Alignment is normal. There is approximately a one-quarter loss of height.

ASSESSMENT: I have made the below statements to a reasonable degree of medical certainty.

Mr. Smith is a middle-aged man who was injured seriously years ago. He suffered an L4 compression fracture that was treated successfully by Dr. Jones. I have been asked to comment on any injuries he has suffered, and his current medical condition as a result.

In this area of medicine, the means by which patients are evaluated are the neurological examination, neuroimaging, and electrodiagnostic studies when available. These indicate an excellent recovery form his structural spine injury. These will be discussed in detail below.

The neurological examination is an important part of this assessment. He has undergone examinations by two neurosurgeons, and more recently a physiatrist. All were normal, and showed no evidence of nerve damage.

Electrodiagnostic studies are also helpful adjuncts in these assessments. Dr. Pont performed such an assessment in August 2014, and it showed no evidence of motor damage.

Neuroimaging is the most important part of these evaluations. The compression fracture had worsened, and he underwent an L3-L5 fusion by Dr. Jones on August 28, 2013. He made an excellent recovery. On October 10, 2013, Dr. Jones recommended that the patient return to work. He could transition to full duty and would not need a brace.⁴

Mr. Smith has made an excellent recovery from his injury. As it occurred after an incident at work, causation is established. It has been capably treated by Dr. Jones. Other records indicate that he has returned to work and is functioning at a “full work schedule.” He requires daily medication and rare opioids. According to the sixth version of the American Medical Association Guidelines, he has a whole person impairment of 4% (see below). He has minimal functional impairment and minimal disability. He could return to work activity at the USDOL medium level.⁵

If other records become available such as healthcare provider notes, imaging studies, deposition testimony, or video surveillance, these should be obtained and sent to me for review. If he has seen Dr. Jones subsequent to May 21, 2014, those notes should be obtained and sent to me for further review.

Signed under the pains and penalties of perjury, this 31st day of October, 2017.

 

Stephen Saris, M.D.
Lecturer in Neurosurgery
Harvard Medical School
Attending Neurosurgeon
Brigham & Women’s Hospital

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⁴ On May 24, 2014, Dr. Jones stated “from the spine fracture and the surgery perspective, I think he has recovered and there should not be any strict limitations. The limitations maybe no strenuous activity, no heavy lifting…”
On April 3, 2016, Dr. Montview, a physiatrist, saw him. He had chronic low back pain and had not been seen for several months. “He has been doing fairly well with his full work schedule.” He took two oxycodone tablets per week and two tramadol tablets per day.
⁵ UNITED STATES DEPARTMENT OF LABOR, DICTIONARY OF OCCUPATIONAL TITLES, AND JOB CLASSIFICATIONS
MEDIUM WORK: Employee may exert 20 to 50 pounds of force occasionally (< 1/3rd of the time) and/or 10 to 25 pounds of force frequently (1/3rd or 2/3rds of the time) and/or greater than negligible up to 10 pounds of force constantly (> 2/3rds of the time) to move objects. Physical demand requirements are in excess to those for light work.

 

	Net adjustment 1. (GMFH-CDX) = NA7 2. (GMPE-CDX) = 0 3. (GMCS-CDX) = 0 Net adjustment (sum of above three)= – 2
	CDX-GRADE MODIFIER=   0     = Grade modifier A FINAL WHOLE PERSON IMPAIRMENT= 4% Functional history8
	PDQ	Grade modifier	Activity level
	0	0	asymptomatic or inconsistent symptoms
	1	0-70	pain, symptoms with strenuous/vigorous activity
	2	71-100	pain, symptom with normal activity
	3	101-130	pain, symptoms with less than normal activity
	4	131-150	pain, symptoms at rest, limited to sedentary activity

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⁶ Guidelines to the Evaluation of Permanent Impairment, 2008 American Medical Association, Library of Congress
⁷ “This is 2 or more points higher than the class assignment and therefore discounted.” page 584, 6th version AMA Guidelines
⁸ Subjective complaints without objective physical findings or significant clinical abnormalities are generally assigned class 0 and have no ratable impairment. Page 561 and 575, 6th version AMA guidelines