MEDICAL CLAIMS EVALUATION SERVICE, LLC
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MEDICAL CLAIMS EVALUATION SERVICE, LLC
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Medical Claims Evaluation Service, LLC PO Box 22272 Pittsburgh, PA 15222 1-412-551-8771 May 4, 2004
Attorney of Record, Esquire Lawyers Building Anytown, PA 15897
Re: PATIENT NAME Date of Injury: January 18, 2004
An evaluation on PATIENT NAME, aged 38, was completed on May 4, 2004 for the purpose of creating this report. Records and radiological films and reports were reviewed. A list of records available for this review is attached to this report and is a part of the report. Mr. PATIENT NAME informed me was an unrestrained driver in a SUV when another vehicle struck his vehicle from the driver’s side near the rear wheel. The force spun his vehicle around and his vehicle hit a wall head on. The air bags deployed. He first attended to his wife who was a passenger and had a large laceration of her forehead. He then rode to the hospital in the ambulance with his wife. He ignored his own symptoms due to his wife’s injuries, but on January 19, 2004 he went to The Regional Hospital emergency room complaining of pain in the cervical spine and headaches. At the emergency room, he had x-rays and was diagnosed with a cervical strain. He was complaining of symptoms in his neck, chest and arms. He was treated conservatively. X-rays of the cervical spine were reported with minor changes at C6-C7. He continued to have pain in his neck in the midline and particularly in both trapezius muscle areas in both middle and proximal areas. He was treated with anti-inflammatory medications. On January 23, 2004, he saw Dr. Richards who sent him to physical therapy treatment with no relief. When he had continued symptoms, an MRI was done on February 14, 2004 at MRI Center. I have reviewed both the reports and the films from that MRI. Mr. PATIENT NAME has significant findings on that MRI. There is no evidence of degenerative disc disease or degenerative joint disease except for some very small spurs at C3-C4. He has a large, acute soft disk protrusion at C6-C7 impressing the left C7 nerve root. At C4-C5 and C5-C6 he has large right sided disc herniations trapping the C5 and C6 nerve root. These are very dramatic disk protrusions and appear to be soft disks. That is, they appear fresh and juicy as opposed to dry and degenerative. Mr. PATIENT NAME was evaluated by a neurologist on March 2, 2004. The neurologist started conservative treatment, but said surgery will likely be needed. He is taking Neurontin for the nerve irritation. Current Symptoms Mr. PATIENT NAME is currently complaining of neck pain, pain in both trapezius muscle areas and occipital headaches. At the present time, he does not have arm pain. He has decreased range of motion in his neck. He is having sleep disturbance and difficulty concentrating. He is currently attempting to work in the body shop which he owns. He is doing what he is able to do but is unable to do his full work. He normally did a lot of the physical bodywork and a lot of mechanical work, but at this time he is limited to helping out in the office and trying to keep the business running. If there was any substitute for him, he would not be working at all. Past History Mr. PATIENT NAME informed me that he had chiropractic treatment on his low back about seven years ago. He has never had any specific treatment, symptoms or diagnostic studies performed for his neck to his knowledge. Physical Evaluation Evaluation of the cervical spine reveals a short, thick neck. There is mild decreased range of motion especially with side tilt. On left side tilting paresthesias are produced in the left arm to the fingertips. Upper extremity static neurologic exam is normal, however. He has tenderness in both trapezius muscle areas and tenderness in both scalene areas. Impression Herniated nucleus pulposus, acute, C4-C5, C5-C6 on the right side. Herniated nucleus pulposus, acute, C6-C7 on the left side. Discussion Mr. PATIENT NAME has about as dramatic of findings on his MRI of the cervical spine as one can find. These appeared to be very pronounced disk protrusions with soft disk material. They do appear to be affecting at least two different nerve roots in his cervical spine. It is amazing that he does not have severe neurologic symptoms. His canal appears just wide enough to allow the neural tissue to partially escape the impress of the disks. Treatment for his cervical spine will be problematical. One is hesitant to do a disk excision and fusion at three levels. However, it is difficult to see how one level should be treated and another not treated. In addition, without a specific neurologic deficit, surgery is difficult to recommend. It is my opinion within a reasonable degree of medical certainty, that Mr. PATIENT NAME will require one or more cervical spine surgical procedures in the near future. Most likely these will involve the use of a plate for a multilevel cervical fusion. Multilevel cervical surgery results in some decreased range of motion of the cervical spine on a permanent basis and transmittal of stress to the levels above and below the surgery. The injury to his cervical spine is permanent. It is my opinion within a reasonable degree of medical certainty that Mr. PATIENT NAME is currently disabled from his usual job in the body shop. He is able to perform some sedentary activities on his own volition. It is totally inadvisable for him to be active or to engage in any physical activity involving his upper extremities or vibration, etc. He will remain disabled until his cervical problem is resolved. At that time he may be able to increase his activity somewhat, but it is unlikely he will regain full activity status in the future. In the meantime, he continues to have symptoms of neck pain and headache which are directly referable to his injuries. Within a reasonable degree of medical certainty, all of the injuries found in this evaluation were sustained by Mr. PATIENT NAME on January 18, 2004 and were a direct and sole result of his vehicle accident. I do not believe any prior condition is contributing in any way to his symptoms. I do not believe it is possible for him to have done heavy mechanical work without symptoms or treatment if these disk conditions had been present pre-injury. His MRI appearance is that of recent protrusion rather then a chronic slow developing process. Indeed his x-rays show only minimal degenerative disc disease at one space. All of the above opinions have been rendered within a reasonable degree of medical certainty. The opinions are based upon history, physical examination, records and X-ray review and my extensive experience as an orthopedic surgeon who has treated such injuries many times. If further information is needed, please let me know. Sincerely,
Orthopedist Name, MD FACS |
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