On June 7, 2005, this 43 year old claimant injured his right shoulder while lifting a shopvac out of a van. After lifting the shop-vac, the claimant felt a sharp pain in his back and pain down his left leg. The claimant went home and rested. The claimant tried to utilize treatment modalities, such as ice and heat that he had learned due to previous back injuries. The pain did not improve, however, and the claimant ultimately sought treatment.
On July 13, 2005, the claimant went to the St. Joseph's Hospital emergency room with mild to moderate back pain that he described as burning, sharp, and radiating. The claimant was diagnosed with a lumbar sprain and prescribed medication. See Exhibit 1.
On August 2, 2005, Dr. Kennedy, who performed the claimant's previous back surgeries examined the claimant, who reported pain from the base of the lumbar spine with radiating pain from the right posterior lateral thigh to the foot. Dr. Kennedy diagnosed sciatica. A CT
myleogram performed on August 9, 2005, showed a disc herniation at L3-L4 lateralizing to the right and extruding into the foramen proximally on the right, effacement of the right L4 nerve root, and evidence of a fusion with posterior instrumentation at L4-S1. See Exhibit 2.
On August 23, 2005, the claimant began undergoing conservative care with Dr. Barry Feinberg and Dr. Rachael Feinberg. The claimant underwent treatment with medication, physical therapy, and a series of injections, which included epidural steroid and transforaminal epidural steroid injections, without relief. On October 12, 2005, Dr. Barry Feinberg noted there were two separate pains the claimant was experiencing. The claimant's right lateral pain was felt to be consistent with his previous surgery and, possibly, the new herniated disc. See Exhibit 4.
On October 18, 2005, Dr. Kennedy recommended surgery. On January 9, 2006, the claimant underwent: (1) The: removal of previous instrumentation from L4-S1; (2) A L3-L4 hemilaminectomy, discectomy with foraminotomy, and (3) A fusion at L3-L5 with bone morphogenetic protein (BMP). Post-surgery, Dr. Kennedy noted the claimant did not have much leg pain. When the claimant began aquatic therapy, the therapist, on April 15, 2006, noted the surgery had significantly improved the claimant's symptoms and he no longer had right lower extremity pain. However, the claimant complained that his legs became fatigued easily and he had a cold feeling in his low back, anterior thighs, and calves. See Exhibits 2, 5, and 7.
On May 9, 2006, the claimant reported limited range of motion, substantial pain in the lower lumbar area, a very tight sensation with a cold feeling at times, and that he had not had much improvement despite the therapy and his range of motion was very limited. Dr. Kennedy thought "a lot of the pain is due to the fact that this is a second time operation." He recommended that the claimant resume his treatment with Dr. Barry Feinberg and Dr. Rachael Feinberg. See Exhibit 2.
The claimant was making improvement with his lumbar pain by the time he saw Dr. Kennedy on August, 26, 2006. However, he still complained of a cold sensation in the lower legs in August and September of 2006. Dr. Kennedy was not sure why the claimant was having these symptoms, but thought there may be some degree of nerve root irritation left over from the original injury's involvement of tight stenosis. An MRI, obtained on October 6, 2006, did not show any evidence of further disc herniations. See Exhibit 2.
The claimant participated in physical therapy and received injections, but continued to be symptomatic. His main complaint was the cold sensation. On October 5, 2006, Dr. Rachel Feinberg was quite certain the sensation was "coming from the autonomic nervous system from the sacrum." On October 12, 2006, Dr. Rachel Feinberg further opined that the claimant was experiencing "high sympathetic outflow because he is fused to the sacrum." See Exhibit 4.
On February 1, 2007, Dr. Kennedy noted the claimant still had quite a bit of pain in the lower lumbar area and legs that had worsened somewhat since his last visit. A spinal cord stimulator was implanted for the claimant's postlaminectomy syndrome on February 12, 2007. The stimulator felt as if it was enhancing the claimant's symptoms and was removed four days later. The claimant then underwent dorsal median nerve root blocks, thoracic facet joint injections, and a lumbar facet injection. His diagnoses included postlaminectomy syndrome of the lumbar spine, thoracic radiculopathy, and pain in the thoracic spine. See Exhibits 2 and 4.
On May 23, 2007, the claimant bent over to look at a pot and felt pain in his left lower back. He presented to Barnes-Jewish St. Peters Hospital and given Dilaudid and Diazepam. Dr. Kennedy, on May 24, 2007, ordered a CT scan that showed a solid posterolateral fusion from L4 to the sacrum bilaterally but no significant posterolateral bony fusion at L3-L4. See Exhibits 2 and 10 .
On May 31, 2007, Dr. Rachel Feinberg documented the claimant "did get quite a bit better with physical therapy and injections but the highly sympathetic outflow sensation or buzzing sensation of the sacrum did not improve." See Exhibit 4.
The claimant saw Dr. Barnardi and Dr. Coyle for second opinions. On July 18, 2007, Dr. Bernardi noted the claimant had an "extraordinarily complicated history of back pain." The claimant advised, after surgery in 2006, the pain he experienced "preop was pretty much gone," but he developed a cold feeling in his legs and his back and legs fatigued easily. Recently, he experienced severe low back pain that radiated into the anterior aspect of his left thigh. The claimant reported his left leg pain was different than his pre-operative leg pain, and it traveled directly from the anterior aspect of his thigh down and did not cross into the medial aspect of the thigh distally. Dr. Bernardi diagnosed a L3-L4 pseudoarthrosis and a possible new onset of left lumbar radiculopathy. The claimant was trying to heal his fusion without further surgery. See Exhibit 11 .
Dr. Kennedy diagnosed a non-union on August 2, 2007, and recommended a revision surgery. Dr. James Coyle, on October 24