On July 12, 2007, Claimant was working for Employer in its fabrication shop. He was assigned to unload large sheets of metal weighing between 60 and 80 pounds. Claimant was sliding the sheets off a table, loading, and stacking them on to an adjoining table with a twisting motion, when he felt a pop in his lower back followed by immediate pain that shot up his back to his shoulder and to his pelvic region. Claimant reported the injury to Employer, and filled out an accident report. Claimant was offered the option of seeing Employer's doctor, but declined. He wanted to go on his own to a chiropractor for a re-alignment.
On July 13, 2007, Claimant saw Dr. Crane, a spine surgeon, and gave a history of lumbar spine pain for one and one-half years, with increased pain from lifting and twisting at work the day before. He reported radiating pain into his left hip to his leg. Dr. Crane noted the MRI of 2005 showed an HNP at L5-S1 and that Claimant had relief from chiropractic manipulation. Dr. Crane requested a repeat MRI, and prescribed medication and physical therapy. He diagnosed a back sprain.
An MRI was performed on July 16, 2007, which showed a left paracentral disc protrusion and annular tear causing mild to moderate left lateral recess stenosis at L5-S1 with potential impingement of the transiting nerve root, and mild diffuse disc bulge at L1-2 without significant central canal or neural foraminal stenosis.
When Claimant began physical therapy on July 18, 2007, he denied radiculopathy. He reported having chiropractic care for his current complaints with good results.
Claimant also saw Dr. Chapel, a chiropractor on July 13, 2007, and gave a history of lower back pain and discomfort since July 2006, which comes and goes, and indicated the condition was getting slightly worse. He denied the injury was work related. Claimant received
numerous chiropractic treatments under his private insurance between July 13, 2007 and October 10, 2007.
On September 14, 2007, at a physical therapy session, Claimant reported a 90 to 92 percent improvement and stated he was able to run for two and one-half miles, and bike for approximately eight miles without pain.
On August 27, 2007, Claimant's attorney sent a letter to Employer's safety manager, informing Employer Claimant was currently receiving medical treatment through a physician of his own choosing. Claimant's attorney asked Employer to inform Claimant if Employer preferred Claimant to see a doctor of Employer's choosing. Employer did not respond.
Leading up to August 27, 2007, Claimant incurred the following medical expenses:
July 13 through August 27, 2007: Crane Sports Medicine \$264.00
July 13, 2007 through August 1, 2007 Chapel Chiropractic \$679
July 16, 2007 St. Luke's Center for Diagnostic Imaging \$3,275
July 18, 2007 through August 8, 2007 St. Louis Physical Therapy \$940.09
July 16, 2007 Diagnostic Imaging \$231
Claimant incurred the following medical expenses between August 27, 2007 and October 10, 007:
Crane Sports Medicine - $\ 204 minus a 46.68 insurance adjustment leaving a balance of $\ 157.32
Chapel Chiropractic \$1,047.50
St. Louis Physical Therapy - \$1,335 minus a \726.30 insurance adjustment leaving a balance of \ 608.70
Claimant missed work from July 12, 2007 until October 15, 2007, at which time Dr. Crane released him to full duty work as a sheet metal worker.
Claimant saw Dr. Margherita, a pain management specialist on November 11, 2009 because of a flare up of his back injury. He told Dr. Margherita he had a back injury in 2007, did treatment, and had pain relief until a week ago. Dr. Margherita diagnosed acute lumbar radiculopathy and prescribed medication. Another MRI was performed on September 8, 2010, which revealed no significant interval change when compared to the prior study.
Currently Claimant has lower back pain including pain in his left pelvic region, and numbness in his left leg. Sometimes he has flare-ups of his pain, and he returns to Dr. Margherita who provides him with pain medication. He stretches, and is careful with lifting. Driving, heavy lifting, and not working cautiously make his symptoms worse. Before July 12,
2007, Claimant had mild back discomfort, but since July 12, 2007, he deals with pain on a daily basis.
Claimant's attorney referred him to Dr. Volarich who saw Claimant on three separate occasions, issued four reports, and testified twice on behalf of Claimant. Dr. Volarich first examined Claimant on April 23, 2008. Claimant told Dr. Volarich he experienced flare-ups of back pain since 2002. He told Dr. Volarich he underwent chiropractic treatment and saw Dr. Curylo when he had flare-ups. He told Dr. Volarich that prior to July 12, 2007, if he had a hard day of work his back hurt, and he would go home and ice it or use a home traction device. He reported he had flare-ups about once every three months. Upon examination he had minimal loss of motion in his lumbar spine, no diffuse spasm, and straight leg raising was 90 degrees bilaterally without radicular symptoms.
As a result of the injury of July 12, 2007, Dr. Volarich diagnosed aggravation of lumbar syndrome with progression of disc protrusion L5-S1 without persistent radiculopathy. He opined Claimant's work accident that occurred on July 12, 2007, was the prevailing or primary factor causing the aggravation of his lumbar syndrome and progression of his disc protrusion that required conservative treatment. He rated Claimant's disability at 20\% PPD of the body as a whole at the lumbosacral spine due to the aggravation of his lumbar syndrome and progression of disc protrusion at L5-S1 without persistent radicular symptoms. Dr. Volarich opined Claimant will require ongoing care for his pain syndrome in the form of prescription and over the counter medications, and physical therapy.
Dr. Volarich issued a supplemental report dated October 20, 2008 after he reviewed Claimant's MRI scans of May 19, 2006 and July 16, 2007. After reviewing and comparing the MRI scans Dr. Volarich concluded there was some progression of the disc protrusion between May 19, 2006 and July 16, 2007 causing neuroforaminal narrowing on the left. He stated the protrusion also appeared to touch the S1 nerve root without causing significant impingement upon it.
Dr. Volarich examined Claimant again on March 10, 2010, and issued a supplemental report. Claimant reported in November 2009 getting out of his truck and having a recurrence of low back pain into his left buttock to his anterior hip. On November 11, 2009, he saw Dr. Margarita who noted he had relief from his pain until the incident stepping out of his truck a week earlier. There was numbness and tingling in his left leg going to the anterior hip. He had tenderness at L5 and loss of extension. Dr. Margarita diagnosed acute lumbar radiculopathy and treated him with medication. Claimant had no further therapy and denied any new injury to his low back. Claimant told Dr. Volarich his baseline symptoms were the same as in Dr. Volarich's report of April 23, 2008. However, Claimant reported when he gets a flare-up he knows he will be out of commission for about three days, basically having to stay in bed, take medications and be barely functional. He continues to do a home exercise program of stretching and calisthenics to maintain his functionality, but during a flare-up it will take him a month of these types of exercises to return back to baseline. He told Dr. Volarich he cannot work if he is on medications so he rests and gets off medications as quickly as possible. He reported continuing pain beginning in the low back on the left and radiating around the pelvis to the anterior leg/groin area with numbness into the anterior thigh down to the knee. It is made worse with lifting at around 50 pounds. As long as he is at baseline, he can sit, stand and walk without difficulty, but when
he gets a flare-up, which occurs about once every three months, he is out of commission. Claimant reported he was able to return to work full duty while at baseline and had no difficulty with working full duty as long as he was very careful to avoid those activities that cause flares. Claimant reported he had none of those problems before July 12, 2007.
Dr. Volarich testified Claimant's work accident of July 12, 2007 was the prevailing factor in causing the progression of the disc protrusion which is shown by the change between the two MRIs, in 2006 and 2007. Dr. Volarich testified Claimant missed approximately three months of work when he was undergoing care for his work injury, and that was a reasonable period of time for him to be off work while receiving conservative treatment. He further testified the care Claimant received appeared to be reasonable and necessary, and the bills appeared to be reasonable and customary charges for treatment within the metropolitan area.
Dr. Volarich reevaluated Claimant on April 4, 2011, prepared a second addendum to his report of April 23, 2008, and again testified on behalf of Claimant. Dr. Volarich took a history of Claimant having a flareup of low back and left lower extremity pain in August 2010 prompting a visit to Dr. Margherita on September 1, 2010. Dr. Margherita diagnosed an acute exacerbation of low back pain with radiculopathy and sent Claimant for an updated MRI while treating him with medication. The MRI which was performed on September 8, 2010 showed no interval changes but noted a herniation to the left at L2-3 with a protrusion to the left at L3-4 along with bulges at L1-2, L4-5, and L5-S1, mild left foraminal stenosis at L2-3 and L3-4 and bilaterally at L4-5 and L5-S1. Dr. Volarich felt the report stated no interval changes, was different from previous MRI reports that noted no herniations at L2-3, but noted protrusions at L4-5 and L5-S1. On September 15, 2010 Dr. Margherita noted Claimant had received moderate benefit from the medication, but still had radicular symptoms into the left pelvis and hip. Examination noted a loss of sensation in the L3 dermatome and Dr. Marherita sent him for an EMG study which showed the presence of an L3 radiculopathy. On September 20, 2010, Dr. Margherita recommended a left sided L3 nerve root block and on December 16, 2010, wrote a letter stating Claimant needed injections and physical therapy. Claimant never received the injections or the therapy.
Dr. Volarich examined Claimant and found he had decreased range of motion in the lumbar spine with no significant spasm, and straight leg raise was accomplished to 90 degrees bilaterally without radicular symptoms. Dr. Volarich diagnosed aggravation of lumbar syndrome with progression of disc protrusion at L5-S1 without persistent radiculopathy as a result of the accident of July 12, 2007, and his opinion regarding PPD remained the same.
Dr. Robert Bernardi, a neurosurgeon, examined Claimant on March 11, 2009, prepared a report, and testified on behalf of Employer. Upon examination Claimant's left hip was a little bit irritable, otherwise his general physical examination and neurological examination were normal. Claimant's straight leg raising test was negative. Dr. Bernardi reviewed the MRIs from May 2006 and July 16, 2007, and testified there may have been a subtle worsening of the disc bulge at L5-S1 from May 2006 to July 2007. Dr. Bernardi compared the films side to side and saw no new acute abnormality on the study from 2007 compared to the study from 2006.
Dr. Bernardi diagnosed multilevel degenerative disc disease in his back, a small left L5S1 disc bulge or disc protrusion, and back and leg pain of uncertain etiology. Dr. Bernardi testified the work injury of July 12, 2007 was not the prevailing factor in the cause of his
degenerative disc disease or the disc protrusion, because Claimant had those same findings on the 2006 MRI scan. He testified it is possible that the slight worsening of his disc bulge is post traumatic and related to the work accident, but he did not believe the work accident was the prevailing factor in causing the possible worsening of the disc bulge.
He testified Claimant's work accident of July 12, 2007 was the prevailing factor in causing the episode of back pain he experienced in July 2007. He testified Claimant had the onset of rather severe back pain, he reported it, it was documented, he sought treatment for it, and then he got better, which is typically what happens with people who have episodes of back pain. He testified it appeared based on the records and history, Claimant's lifting incident at work was the cause of his back symptoms. Dr. Bernardi testified Claimant sustained no PPD as a result of the work injury of July 12, 2007. Dr. Bernardi also testified as of the date he saw him he did not believe there was any need for any further medical treatment for Claimant related to the work injury, and he was at maximum medical improvement. Dr. Bernardi agreed the treatment Claimant received between July 12, 2007 and September 14, 2007 was reasonable and necessary to address the symptoms he developed following the July 12, 2007 work accident.