At the time of her accident on March 1, 2001, the employee was working for Ste. Genevieve Country Mart as a deli assistant. The employee's accident occurred after she had mopped a concrete floor in the deli. When the employee walked from the concrete floor to the tile floor, she slipped and injured her back. Although she caught herself on a table and did not fall to the floor, the employee felt immediate pain in her low back.
Although the employee did not report her injury at the time, within a few days, her back pain got worse and she began experiencing pain in her right hip and right leg. After reporting the accident to her supervisor, the employer-insurer authorized treatment with Dr. Russell Cantrell at Orthopedic and Sports Medicine in St. Louis, Missouri.
Dr. Cantrell, who specializes in physical medicine and rehabilitation, examined the employee on March 22, 2001. Dr. Cantrell felt the employee's subject complaints of lumbar back pain were "significantly out of proportion to her objection examination," and did not believe she had any evidence of neurologic deficits. Based on his examination, Dr. Cantrell did not order additional diagnostic studies. He also felt the employee was "exaggerating her symptomotology." Notwithstanding these conclusions, Dr. Cantrell felt it was possible the employee might have strained her lumbar spine, and recommended physical therapy and prescription pain medication. Dr. Cantrell concluded his examination my noting, "given her multiple non organic findings on clinical examination, it is not likely that her subjective symptoms will respond positively to physical therapy or the antiinflammatory medication. I anticipate her reaching maximum medical improvement within three to five weeks of today's visit" (Employer-insurer Exhibit 2).
After several physical therapy sessions, the employee returned for a final visit with Dr. Cantrell on August 12, 2001. In the first paragraph of his April 12, 2001 report, Dr. Cantrell notes the employee was continuing to complain of low back pain with no improvement after the physical therapy. He then noted that she had discussed her condition with her attorney who had suggested she might need an MRI in order to evaluate her complaints. Although the workers' compensation insurance carrier had apparently authorized the MRI, Dr. Cantrell indicated that based on his initial clinical examination, he did not feel further diagnostic studies were necessary. Dr. Cantrell then concluded by stating, "she has been referred back to her attorney whom she has consulted with in the past for further medical recommendations" (Employer-insurer Exhibit 4).
Based on Dr. Cantrell's report, the employer-insurer denied further medical treatment, and the employee's attorney scheduled the employee for an evaluation by Dr. David Robson. Dr. Robson is an orthopedic surgeon with a fellowship in spine surgery who practices with St. Louis Spine Care Alliance.
Dr. Robson first examined the employee on May 16, 2001. At the time of this examination, she was complaining of low back pain, bilateral buttock pain and right leg radiating pain (Employee's Exhibit A, page 4). Dr. Robson initially diagnosed a lumbosacral strain, but recommended an MRI because of her radicular complaints of leg pain (Employee's Exhibit A, page 6). The MRI performed July 25, 2001 confirmed the employee had degenerative disc disease with a posterior central herniation of the L5/S1 disc with migration of a small disc fragment (Employee's Exhibit A, page 7).
After reviewing the MRI, Dr. Robson concluded it was not a large disc herniation, and recommended conservative treatment (Employee's Exhibit A, page 7). At the time Dr. Robson recommended conservative treatment on August 14, 2001, the employee was no longer working for Ste. Genevieve Country Mart, and had decided to go back to school. In an Office Visit Report, Dr. Robson indicated the employee was available for sedentary, light duty work, or school (Employee's Exhibit C). Although Dr. Robson's notes indicate he was hoping to obtain approval from the employer-insurer to proceed with conservative treatment, the employer-insurer responded by sending the MRI to Dr. Cantrell for a supplemental opinion. In a letter dated August 13, 2001, Dr. Cantrell agreed that the MRI showed a central disc protrusion at the L5/S1 level. He concluded that the herniated disc was not "substantially caused by her reported work injury from March 1, 2001." He added, "this opinion is based on the fact that Ms. Fischer has had two prior episodes of sciatic nerve pain, one occurring six years ago with pregnancy and the second occurring one-and-a-half years ago" (Employer-insurer Exhibit 6).
Based on this letter, the employer-insurer refused to authorize the suggested treatment by Dr. Robson. The employee testified that she had no income, no health insurance and was living on student loans and assistance from HUD to pay her rent.
The employee's next visit with Dr. Robson occurred on January 22, 2002. Dr. Robson reported that the employee was "slightly better, but still complaining of severe right buttock pain and low back pain" (Employee's Exhibit A, page 9). Dr. Robson felt the employee had made no progress, and recommended a C/T myelogram. After the C/T myelogram was completed on January 29, 2002, Dr. Robson reiterated that