Ms. Kim Hulsey, 47 years old as of the date of hearing in this matter, has worked as either a waitress or as a bartender since the age of sixteen. Prior to her work injury on 12/01/00, Ms. Hulsey had been working for a year and a half as a waitress at Hawthorne Restaurants. Claimant recalls that while standing on a chair at the restaurant putting up Christmas garland with a staple gun, she attempted to step onto the arm of the chair for leverage, causing the chair to flip, and causing the claimant to fall to the floor. Claimant recalls suffering from a bad burning sensation on her right side to her hip, but continued to work for another hour before going home. Claimant recalls that evening, a Friday, she was unable to lift her right arm to hang up clothing, and that her back and rear end were both hurting bad. Claimant recalls returning to work the following Tuesday while tolerating pain into her back and hip.
Claimant recalls that she had good and bad days thereafter, but was still having complaints of pain around Christmas of 2000, when her request for medical treatment was denied by Kathy, one of the owners of the restaurant.
Claimant was referred by a neighbor to Dr. Tessier, and the first medical evaluation of Ms. Hulsey post her accident on 12/01/00 was performed by Dr. Tessier on 1/11/01 (See Claimant’s Exhibit A). Dr. Tessier took a history of injury; had x-rays taken of the lumbar spine; performed a physical examination; and concluded that claimant suffered from “mechanical low back pain with possible lower lumbar disc protrusion”. In his notes dated 1/11/01, Dr. Tessier noted among others, that straight leg raise exam was negative bilaterally, and that the tenderness complained of was “in the right sacroiliac region with some mild tenderness at the sciatic notch on the right side only”. Claimant was given a trigger point injection to her right sacroiliac joint, was prescribed physical therapy and anti-inflammatory medication, and was to have an MRI in the event of ongoing complaint as to numbness and tingling in her right leg. Ms. Hulsey attended three of six sessions scheduled at ProRehab through 2/02/01(See Claimant’s Exhibit B). Claimant was advised by Dr. Tessier to remain off of work from 1/11/01 to 1/22/01. Claimant was subsequently terminated from her employment by the employer once advised she would not be able to come to work for a week.
There is no history of further treatment until 7/16/01, when the claimant returned to Dr. Tessier with ongoing complaints of an aching pain in the back of her pelvis, and of a numb sensation down the right lower extremity into the feet. The medical records indicate that on 7/23/01 the claimant had both an MRI of the lumbar spine and of the pelvis. The MRI states, in part: “Degenerative disk disease predominates at the L5-S1 level. There is a focal disk protrusion or herniation centrally within the canal, which may lateralize slightly to the left of midline”. The MRI of the pelvis was interpreted as showing no specific sacroiliac pathology (Claimant’s Exhibit C). On 7/26/01 Dr. Tessier reviewed the results of the MRI and suggested epidural steroid injection. The next note, dated 12/31/01, states that the claimant was now ready to proceed with epidural steroid injection. Claimant was referred to Dr. Sohn for further treatment.
Claimant met with Dr. Sohn on 1/08/02. Dr. Sohn took a history of complaint, reviewed the medical history, and prescribed physical therapy, medication, and administered a trigger point injection for what he diagnosed as sacroiliitis and myofascial pain syndrome (See Claimant’s Exhibit D).
There is no further medical record in evidence until 6/22/02, when Ms. Hulsey presented to the emergency room at St. Luke's Hospital with complaints of severe right sided low back and right hip pain. Ms. Hulsey acknowledged at hearing that on 6/22/02 she was taken by ambulance to the hospital after her back "went out" and she was unable to straighten up after attempting to bend over with a towel to remove some cat poop from the carpet. X-rays of the lumbar spine showed no fracture or subluxation. Claimant was treated and discharged that same day. On 6/27/02 Dr. Tessier performed a physical examination, and noted that the claimant presented with a positive straight leg raise test at 45 degrees on the right side. He suggested epidural injection for what appeared to be right sided nerve root impingement. Claimant met with Dr. Tessier on 8/11/02, and Dr. Tessier discussed possible surgical intervention in the event epidural injection by Dr. Sohn did not work.
On 8/19/02 Ms. Hulsey returned to Dr. Sohn, and received an epidural steroid injection to her low back. On 9/03/02 Dr. Sohn met with Ms. Hulsey, reviewed the MRI, and recommended further injection to the low back at two levels. On 9/04/02 Dr. Sohn performed the two injections. Claimant returned to Dr. Sohn on 9/18/02, and reported 75 to 100\% improvement in her low back.
On 6/22/03, Dr. David R. Lange, board certified in orthopedic surgery, performed an examination of Ms. Hulsey at the request of the employer's insurer. Dr. Lange solicited physical complaints from Ms. Hulsey, reviewed certain medical records, and performed a physical examination. Dr. Lange concluded that the claimant suffered a right sacroiliac joint injury as a consequence of falling on the one side of the pelvis. Dr. Lange concluded that the claimant had reached maximum medical improvement as of the date of his examination (Employer and Insurer's Exhibit No. 1, at p. 11).
Subsequent to his evaluation of Ms. Hulsey on 6/22/03, in November of 2004 Dr. Lange was provided with records relating to a spinal fusion had by the claimant. Dr. Lange also had the opportunity to see Ms. Hulsey on 6/23/05 by referral from Dr. Greco, an oncologist and hematologist in the same building who was treating Ms. Hulsey at the time. Dr. Lange notes that Ms. Hulsey completed a pain drawing that indicated that she still had right low back symptoms and right leg complaints, and similar pain levels to what she had indicated after completing the same form while seeing Dr. Lange in 2003.
As for the finding of disc herniation at L5-S1, Dr. Lange notes that the claimant had a small disc herniation centrally located and extending to the left, asymptomatic side. He notes that such disc herniation was not treated by the fusion surgery had by Ms. Hulsey, inasmuch as the herniation is posterior into the canal, and would require a posterior approach. Dr. Lange, when advised that the surgery involved an anterior retroperitoneal approach, noted that the surgery had by Ms. Hulsey was to remove the inside disc to effect fusion, and was not to treat the herniation, which would not have been seen by this anterior approach (Employer and Insurer's Exhibit 1, at pages 16-17). Dr. Lange goes on to acknowledge that his diagnosis of sacroiliac joint injury could be proved to be incorrect in the event that the fusion surgery performed on Ms. Hulsey had the effect of resolving her pain complaints.
Two months after the evaluation had with Dr. Lange on 6/22/03, Ms. Hulsey met with Dr. David Raskas on 8/25/03. Dr. Raskas took a history of complaint; reviewed certain medical records; had x-rays taken; performed a physical examination; diagnosed the claimant as having discogenic pain at the L5-S1 level; and ordered a current MRI scan. An MRI of the lumbar spine performed on 8/27/03 was interpreted as showing "1. Multilevel degenerative disc and facet disease. Small focal central protrusion L5-S1. Mild protrusion lateralizes slightly to the right at L2-3. 2. Transitional first sacral segment."
On 4/09/04 Dr. Raskas met with Ms. Hulsey to discuss various medical concerns, including as to the lumbar spine. Dr. Raskas notes that he reviewed the old lumbar MRI and states "She has some dehydration of her disks throughout the lumbar spine but the most collapsed significant one is what I would call the L5-S1 segment" (See Claimant's Exhibit F).
On 4/16/04 Ms. Hulsey had a myelogram and post myelogram CT of both the cervical and lumbar spines. The report as to the post myelogram CT of the spine speaks for itself. The only finding noted in the section entitled "Impression" is as to a "very mild stenosis at L3-4 and L4-5."
In his report dated 4/23/04, Dr. Raskas states that he reviewed the CT of the lower spine, and notes, "The L4-5 disk bulges quite a bit. The L5 and what I'll call transitional vertebra does its most collapse and is really degenerative." Dr. Raskas recommended the fusion surgery that he performed with the assistance of Dr. Arenos on 5/14/04.
The operative report, as contained in Claimant's Exhibit F, indicates that Dr. Raskas performed a complete discectomy and anterior lumbar interbody fusion of L5-S1 and L4-5. Subsequent to that operation, Ms. Hulsey suffered groin pain and swelling in her left lower extremity. Doppler ultrasounds indicated a deep venous thrombosis in the proximal, femoral, and iliac vessels.
Studies suggested that the claimant had developed blood clots in her left iliac vein and in the left common femoral artery. Claimant was put on anticoagulants. Claimant further treated for her venous condition by placement of a filter, and a stent in the left common iliac vein (See Claimant's Exhibit L).
Ms. Hulsey testified that she continues to treat with Dr. Greco, who actively monitors her use of blood thinning medication. Claimant recalls seeing Dr. Lange by referral from Dr. Greco concerning complaints she had made as to achiness in her neck and shoulders.
Ms. Hulsey testified as to a constant pain in her left side from below her breast and down her left leg. Ms. Hulsey further reports a right sided lower back ache that comes and goes. Claimant relates that sitting and standing for extended periods of time causes her to suffer pain up and down her left side, and into the left leg and abdomen area. Claimant has
pain when bending to lift from the floor, and uses a gripper to pick things up from the floor. Claimant further notes a general lack of energy, and of loss of bowel control two or three times in a week. Claimant also notes that her sleep is disturbed; that she will get maybe four hours of sleep in a night; and that she awakens exhausted in the mornings. Ms. Hulsey notes that she is unable to walk distances; that she has difficulty walking up inclines; and that her legs are often in pain.
Claimant acknowledged on cross examination that she continued to work until the event at home on 6/22/02 that caused her to seek medical treatment. Claimant further acknowledges that she worked in new home sales in 2003 and into March of 2004, for three months with McBride \& Sons, and for 3 or 4 months with American Heritage.
Ms. Hulsey further relates that she has not sought any back treatment since her release from care by Dr. Raskas in March of 2005, and that the only work limitation imposed by Dr. Raskas was a 25 pound lifting restriction.
The claimant's husband, daughter, and a good friend who has known the claimant for over 20 years all testified as to their observations of the claimant both prior to and subsequent to her injury at work on 12/01/00. The witnesses all testified as to the active life led by Ms. Hulsey prior to her work injury, and as to her ongoing complaints to date as to pain, swelling in the leg, incontinence, and as to her irregular sleeping habits.
Dr. Raymond F. Cohen met with Ms. Hulsey on 2/28/02, took a history of injury and complaint, reviewed certain medical records, and performed a physical examination. Dr. Cohen concluded that the claimant suffered from a lumbar disc protrusion at L5-S1, a right lumbosacral myofascial pain disorder and a right lumbar radiculitis, all of which he related to the injury at work on 12/01/00. Dr. Cohen recommended that the claimant have a lumbosacral and pelvic bone scan; a lumbar myelogram CT; and a lower extremity EMG NCD. In the event the testing was negative, he would further recommend treatment by epidural steroid injection, physical therapy, and medication. Dr. Cohen ruled out a surgical option in the absence of any definite radicular findings (Claimant's Exhibit R, at pages 10-12).
Dr. Cohen had the opportunity to meet with Ms. Hulsey again on 10/5/04, some five or so months post her fusion surgery. Dr. Cohen became aware of the development of a deep vein thrombosis in the left leg post the surgery, and of ongoing care provided by Dr. Greco. Dr. Cohen took a further history from Ms. Hulsey as to her complaints, reviewed certain of the medical records, and conducted a physical and neurologic evaluation. Dr. Cohen concludes that the work trauma suffered on 12/01/00 caused the need for the fusion surgery, and was also the cause of the deep vein thrombosis, inasmuch as the DVT was a result of the fusion surgery.
Dr. Cohen acknowledges that one of the findings contained in the operative note of Dr. Raskas is as to the presence of severe degenerative disc disease at L5-S1 and L4-5. When asked as to the significance of such a finding, he notes:
That compared to her initial MRI scan done in July of '01 and the operation several years ago and going along with her history of progression of the severe back pain, that the disc space had progressively lost its space. In other words, it had gone lower or collapsed and would have been consistent with her ongoing complaints of pain, that once that process had started and the disc protruded, it no longer could support that disc space between L5 and S1.(Claimant's Exhibit S, page 8).
Dr. Cohen acknowledges that it is extremely unlikely for a patient the age of Ms. Hulsey to have as much disc space narrowing in the absence of trauma. He further states, "So if a patient has a history of significant back trauma and has an MRI and as time goes by and the back pain gets worse and then shows collapse of that disc space, then more likely than not the trauma is what caused the need for the surgery" (Claimant's Exhibit S, at page 24).