Was the treatment employee received for his back necessary to cure and relieve his work-related back condition? Was employee's need for treatment medically causally related to his work injury? (That is, did employee's need for treatment flow from the work accident or occupational disease?)
The threshold issue to consider is whether the medical treatment for which claimant seeks compensation was reasonably required to cure and relieve employee of the effects of his work-related back injury. We preface our analysis by setting out the main competing theories regarding the causes of the symptoms and conditions giving rise to employee's two back surgeries.
Employer's expert, Dr. Michael Ralph, believes that the lower extremity complaints prompting employee to undergo the first surgery were caused by diabetic neuropathy. Dr. Ralph believes the right lower extremity complaints that gave rise to the second surgery, including the loss of quadriceps function, were caused by a traction injury suffered during the first surgery. Dr. Ralph steadfastly asserts that employee suffered no nerve root compression at L3 and that none of the diagnostic studies showed any compression.
Employee's expert, Dr. Arden Reynolds believes that employee's symptoms giving rise to the first surgery were caused by a foraminal disc herniation compressing the nerve root at L3. Dr. Thomas Musich concurs. Dr. Reynolds believes that employee's symptoms before the second surgery were also caused by the persistent disc herniation at L3-L4, as well as, a disc fragment compressing the nerve root at L3.
287.140. 1 RSMo provides:
In addition to all other compensation, the employee shall receive and the employer shall provide such medical, surgical, chiropractic, and hospital treatment, including nursing, custodial, ambulance and medicines, as may reasonably be required after the injury or disability, to cure and relieve from the effects of the injury. If the employee desires, he shall have the right to select his own physician, surgeon, or other such requirement at his own expense.
The administrative law judge recounted employee's medical treatment in detail. We concern ourselves with two main treatment events. On July 17, 1998, Dr. Bruce Vest performed a microdiscectomy at L3-L4. During surgery, Dr. Vest observed a large right foraminal disc herniation at L3-L4 compressing the right L3 nerve root. He believed employee's right thigh pain and numbness was caused by this compression.
In December 1999, Dr. Reynolds, a neurosurgeon, performed a second surgery on employee's back. During the surgery, Dr. Reynolds discovered an encapsulated disc fragment compressing the spinal nerve at L3. He removed the disc at L3-4 and performed a fusion.
Dr. Reynolds testified by deposition on behalf of claimant. Dr. Reynolds concluded that employee had a persistent right-sided L3-4 herniated disc with radiculopathy. Dr. Reynolds testified that the cause of employee's herniated disc with acute radiculopathy was the slip and fall on antifreeze on April 23, 1998. He assessed 25\% permanent
partial disability based on AMA guidelines to account for loss of motion and radiculopathy. When asked if employee's symptoms before Dr. Vest's surgery were caused by diabetic neuropathy, Dr. Reynolds explained that diabetic neuropathy did not explain employee's atrophy, clinical findings, or weakness. He stated that diabetic neuropathy would not cause weakness in only one leg; both legs would be affected. Dr. Reynolds pointed out that diabetic neuropathy would not produce evidence of nerve compression at L3 on MRI. Diabetic neuropathy would dissipate within six to nine months. Employee's condition did not improve within six to nine months. Dr. Reynolds testified that the July 1998 surgery by Dr. Vest and the November 1999 surgery by Dr. Reynolds, as well as the other treatment he reviewed, were reasonable and necessary to cure and relieve employee of the effects of his
April 23, 1998, work injury
Employer/insurer submitted the deposition testimony of Dr. Ralph, who also testified by deposition for the first hearing. He testified there was no evidence in the diagnostic studies that employee had nerve root compression at L3. He testified that neither back surgery was necessary. He stated that a traction injury during the first surgery caused employee further medical problems, including the loss of his quadriceps function. When questioned about Dr. Reynolds' description of finding a disc fragment compressing a nerve root, Dr. Ralph asserted that Dr. Reynolds was not truthful in his operative report. He did not believe that any of employee's disability was caused by his work.
Cross-examination revealed Dr. Ralph's unfamiliarity with employee's treatment, symptomatology, and condition. Although Dr. Ralph claimed to perform a thorough review of employee's medical records, he was mistaken about many matters. These mistakes led him to form a negative impression of employee and employee's decisions regarding his healthcare. These mistakes also led him to believe employee was exaggerating his symptoms. We highlight a few such instances:
Dr. Ralph believed employee was using a walker unnecessarily. At the urging of employee's counsel during cross-examination, he reviewed Dr. Selhorst's records in which Dr. Selhorst recommended employee use a walker. Dr. Ralph then conceded employee's use of a walker was reasonable.
Dr. Ralph believed employee exaggerated when he described his pain complaints as "severe" because employee only marked his pain at the level of " 5 " on Dr. Ralph's office intake form. Remarkably, Dr. Ralph was unaware that his own intake form asked patients to rate their pain on a scale of 1 to 5 , with 5 being most severe.
Dr. Ralph concluded that employee went against medical advice by undergoing surgery by Dr. Vest. The medical records reveal that other doctors, including Drs. Reid and Taylor believed employee may have a surgical problem.
We find the opinions expressed by Dr. Reynolds more persuasive than those of Dr. Ralph. Dr. Ralph does not perform back surgeries. Dr. Reynolds does. Dr. Reynolds actually performed a back surgery on employee and saw the extent of employee's back condition during the surgery. Dr. Ralph based his conclusions about the condition of employee's back on diagnostic imaging, radiology reports, his flawed understanding of the medical records, and his misperception about employee's veracity. Dr. Ralph's accusation that Dr. Reynolds fabricated an operative report is simply unworthy of belief and further damages his credibility.
The most compelling reason to accept Dr. Reynolds opinions is because his opinions make the most sense in light of employee's post-surgical improvement. The medical reports and the testimony of Steven Lahey, employee's stepson, establish that the second surgery improved employee's mobility and overall functioning. The surgery would not have provided such relief if employee's quadriceps problem was due to surgically-induced nerve damage as Dr. Ralph urges. Based upon the success of employee's November 1999 surgery as detailed above including Dr. Reynold's discovery of a disc fragment - it is clear that the earlier surgery by Dr. Vest was designed to cure an orthopedic back problem.
Mr. Lahey credibly testified that after the second surgery, employee walked more quickly and his mobility was better. He resumed regular maintenance on his stock car. Employee performed transmission jobs for family members and friends. Mr. Lahey explained that employee was starting to get in the same condition that he was prior to the work injury. He observed employee squatting, crawling, and getting under vehicles. Prior to the
second surgery, employee was unable to perform these activities. Steven Schwegel, employee's physical therapist, testified by deposition that employee significantly improved after the second surgery.