Adjusters Choice. Independent Medical Evaluations

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Dennis Houston
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1 Adjusters Choice Independent Medical Evaluations October 2, 2009 Mr. Dan Johnson Seaword Insurance Company C/O Adjuster s Choice 5040 Greenwood Circle Minneapolis, MN DOL: 07/16/2006 File #: Dear Mr. Johnson: I had the opportunity to perform an independent medical examination on Mr. Timothy Martin on September 30, Before I saw Mr. Martin, I reviewed the medical records that you sent me. These included those from Britton Center, Fairview Lakes Medical Center, Fairview Clinic, Interventional Spine Specialists, Anchorage Neurosurgical Associates, Alaska Spine Institute, Karol Neuropsychological Services, Kim Murphy, M.S., Advanced Pain Centers of Alaska, Dr. Bald, Alaska Regional Hospital, HealthSouth, Dr. Kropp, Surgical Concepts, Alaska Regional Diagnostic Imaging, Dr. Duddy, Norton Sound Regional Hospital, Dr. Ryan - chiropractor, Diagnostic Imaging of Alaska, Ascension Physical Therapy, Midwest Spine Institute, Surgical Concepts, First Report of Injury or Illness, and billing records..during the course of the evaluation, I went over these records with him. There is a Report of Injury or Illness dated July 17, 2006, indicating that Mr. Martin hurt his lower back. His lower back popped. Mr. Martin was seen on July 25, While at work he was lifting a hose which weighed about ten pounds. He had a twisting motion and felt a sudden pop. He initially went to Alaska Native Medical Center and was given muscle relaxants and pain medication. It was felt that he had low back pain with radicular symptoms. An MRI was ordered. A cervical spine MRI was also ordered due to increased numbness in his fingers. He was told to continue with antiinflammatories and muscle relaxants and they would consider physical therapy.

2 Page 2 Mr. Martin had an MRI of his cervical spine on July 25, There was a large protrusion on the left to midline. At C5-6 there was a probable mass effect in the exiting left C6 nerve root. There were no other significant abnormalities. An MRI of the thoracic spine showed several early midline protrusions, none of which caused significant mass effect or adjacent neural elements. The cord was intrinsically normal. An MRI of the lumbar spine showed a large subligamentous protrusion centrally and slightly to the left at L4-5. This caused mass effect of the ventral left lateral aspect of the thecal sac, but not to the exiting nerves. There was a small protrusion centrally and to the left at L3-4. There was no significant mass effect of the adjacent neural elements. There was mild bilateral L4-5 and L5-S1 facet arthropathy. Mr. Martin was seen on July 31, He was referred to Dr. Kropp for selective nerve root block. He was given a Medrol Dosepak and Vicodin. He was referred to physical therapy. I did review chiropractic treatment records from Dr. Ryan, a chiropractor, beginning on August 3, Mr. Martin was seen on August 10, He had been treated with a prednisone burst and was not improving. A referral had been made to Dr. Kropp. He had missed the appointment so it was rescheduled for August 15, Mr. Martin did begin physical therapy on August 10, 2006, and I did review those records of treatment along with continuing chiropractic treatment with Dr. Ryan Mr. Martin was seen in the emergency room because of back pain on September 18, He was given an injection of morphine. Mr. Martin was seen on August 29, Physical therapy was discussed. He was told to continue wearing his back brace. He was told to return to work with restrictions. On September 14, 2006, he did have a transforaminal steroid injection at L4 on the left. Mr. Martin was seen on September 18, 2006, in the emergency room because of back pain. He was given morphine. On October 5, 2006, Mr. Martin had a transforaminal steroid injection at L4 on the left. On November 29, 2006, Mr. Martin saw Dr. Dudey. He felt he had a large L4-5 herniated disk with failure of nonoperative treatment. He recommended microdiskectomy of L4-5 on the left.

3 Page 3 On December 14, 2006, Dr. Dudey performed left-sided, L4-5 microdiskectomy with right-sided foraminotomy at L4-5 with the use of operative microscope. Mr. Martin was seen on December 27, 2006, he was having significant pain. An MRI was ordered. An MRI was performed on January 18, There were postoperative changes at L4-5 on the left; however, centrally and just left to midline there appeared to be a recurrent disk herniation. It was a small fragment almost attached to the disk that effaced the thecal sac and extended to the left of midline. It did not show enhancement, therefore it was felt likely a recurrent herniation. Mr. Martin was seen in the emergency room on January 27, He was told to use a TENS unit. He was given a prescription for Vicodin and Motrin to get through the weekend. Mr. Martin was seen in the emergency room on January 30, He was given morphine and Phenergan. Mr. Martin saw Dr. Kropp on February 26, He wanted to proceed with percutaneous endoscopic diskectomy at L4-5 on the left. On March 9, 2007, Dr. Kropp performed percutaneous endoscopic diskectomy at L4-5 on the left with a blunt laminectomy. Mr. Martin was seen on April 11, He was told to continue with physical therapy. They wanted to perform one more injection at L4 on the left to see if they could calm down the radiculitis. He was given Ambien for sleep. On April 19, 2007, Mr. Martin underwent a transforaminal steroid injection at L4 on the left. Mr. Martin was seen on April 24, They wanted to obtain a new MRI to make certain there were no retained fragments. He was told to continue with physical therapy. Mr. Martin had an MRI of the lumbar spine performed on April 24, It showed status post left L4-5 laminectomy. There was enhancing soft tissue at the operative site consistent with scar formation. There was marked enhancement of a posterolateral thecal sac and around the left L4 nerve tissue, likely a scar. There was no retraction or evidence of arachnoiditis. There was a small recurrent protrusion to the midline of L4-5. It did not appear to be causing significant mass effect on the adjacent neural element. It had not significantly changed in size or appearance from the prior study. Mr. Martin was seen on May 1, It was felt his new MRI looked good. He was still having symptoms. They advanced his physical therapy. He was also to begin job rehabilitation.

4 Page 4 Mr. Martin was seen at Advanced Pain Centers on July 18, He was referred to psychological care to evaluate psychological clearance for a spinal cord stimulator. He was referred for physical therapy. He was given a Lidoderm patch and Zanaflex. Mr. Martin was seen at Advanced Pain Centers on July 30, Flexion/extension films were ordered. He was started on Percocet. An opiate agreement was reviewed. Mr. Martin was seen on August 27, He was told to continue Lyrica. He was referred to a psychologist. He was told to use heel inserts. He was told to use a TENS unit and traction. He was given Percocet. Mr. Martin's physical therapy continued. Mr. Martin was seen on September 21, They wanted to decrease the Lyrica and continue with Lidoderm. He was to continue with Percocet and try Skelaxin. He was given a lumbar brace. Mr. Martin was seen on November 1, 2007, at Advanced Pain Centers. He was told to continue with relaxation. Mr. Martin was seen at the Alaska Spine Institute on November 12, It was felt he had a 13 percent impairment to the whole person for lumbar spine issues, including disk herniation, left lumbar radiculopathy, and ongoing symptoms. Mr. Martin was seen at Anchorage Neurosurgical Associates on July 3, It was felt that he would benefit from a dorsal column stimulator. Mr. Martin was seen at Midwest Spine Institute by Dr. Zeller on January 23, She did not recommend opiates. He was given trazodone, Cymbalta, and Lyrica. They wanted to review his most recent MRI. Mr. Martin was seen on February 4, He was given Percocet. Mr. Martin saw Dr. Britton on March 12, He was told to continue his baseline medications. He was given a prescription for hydrocodone, Lyrica, Cymbalta, and trazodone. He was sent to physical therapy. He wanted to obtain copies of his records for further review. He was sent to psychology. He was told to return in four to six weeks. Mr. Martin was seen on July 8, He needed paperwork for the state to continue his application for Social Security Disability. A form was signed that he was unable to work in the foreseeable future.

5 Page 5 Mr. Martin was seen at the Britton Center on July 14, He was told to continue with his medications. He was given Percocet for break-through pain. Visco therapy was to start after he returned in mid August. It was felt he was not able to do any work then. Mr. Martin was seen on September 26, 2008, at the Britton Center. He was told to continue with his current medications and current treatment. He was given Percocet. Mr. Martin was seen at the Britton Center on October 23, He was told to continue with his current medications and treatment, orthopedic physical therapy, and pool therapy. Mr. Martin was seen on November 20, 2008, at the Britton Center. He was told to continue with his current medications and treatment. Mr. Martin was seen at Fairview Lakes Medical Center, because of low back pain, on November 23, It was felt he had acute-on-chronic low back pain. Mr. Martin was seen on December 19, 2008, at Britton Center. He was told to continue with his current medications and current treatment plan. Mr. Martin was seen at the Britton Center on January 19, He was told to continue with his current medications and treatment plan. He was given Zanaflex, Percocet, trazodone, Cymbalta, Lyrica, hydrocodone, and acetaminophen. Mr. Martin was seen at the Britton Center on February 18, Behavioral therapy was ordered. It was recommended he follow-up with a psychologist and a psychiatrist. He said he could not afford going to the Britton Center, therefore he was told to follow up with a provider closer to his home. He was told to continue with his current medications. He still had Vicodin. He was to continue with his current treatment. He was to follow up in one week. Mr. Martin was seen on February 20, He was given a psychology referral for weekly visits. He was to call the pain clinic every week to report in and get refills of his medications. Mr. Martin was seen on February 25, He was given Percocet. He was to call the pain clinic to arrange for an appointment the following week. Mr. Martin was seen on March 4, 2009, at the Britton Center. He was told to continue with behavioral therapy, current medications, and current treatment plan. Mr. Martin was seen on March 11, He was told to continue with cognitive behavioral therapy. He had missed that day because his truck would not start. He was told to continue with his current medications and current treatment plan.

6 Page 6 Mr. Martin was seen on March 18, He was given Percocet. He was told to continue cognitive behavioral therapy, current medications, and current treatment plan. He was to follow up in one week. Mr. Martin was seen on March 25, He was told to continue cognitive behavioral therapy, current medications, and current treatment plan. He was given Percocet. Mr. Martin was seen at the Britton Center on April 1, He was told to continue behavioral therapy, current medications, current treatment plan, and to follow up in one month. He was given Percocet. Mr. Martin was seen on April 30, 2009, at Britton Center. He was told to continue with cognitive behavioral therapy, current medications, current treatment plan, and to follow up in a month. He was given Percocet. Mr. Martin was seen at the Britton Center on May 8, He was referred to R.S. Medical for a low back home program. Mr. Martin was seen on June 26, He was given trazodone and M.S. Contin. He was told to continue with behavioral therapy, current medications, current treatment plan, and to follow up in one month. Mr. Martin was seen on July 8, He was given hydrocodone, Cymbalta, Lyrica, Zanaflex, and M.S. Contin. He was told to continue with his current treatment plan. Mr. Martin was seen on July 23, 2009, at the Britton Center. He was given M.S. Contin. He was told to continue seeing Dr. Fleming. He had chronic depression with recurrent thoughts of suicide without a plan to act on. HISTORY Mr. Timothy Martin is a 53-year-old male who was involved in a work-related accident on July 17, 2006, while employed by Alaska Trailblazing. He hurt his lower back while he was loading a hose on a truck. He had associated left leg pain. He had an MRI that showed a herniated disk. Conservative treatment failed to relieve his symptoms, and on December 14, 2006, Dr. Dudey performed an L4-5 disk excision. He continued to have symptoms of pain. An MRI subsequent to surgery showed a recurrent disk herniation. On March 9, 2007, Dr. Kropp performed a percutaneous diskectomy. He was then rehabilitated from surgery. His symptoms persisted. An MRI did not show another recurrent disk. He did have a recommendation for a dorsal column stimulator, but that was never done. In December of 2007, he moved to Minnesota. He has treated at the Britton Center. He has had psychological treatment as well as been given various medications, including narcotics, for

7 Page 7 treatment of his pain. He told me that he has continued with medications and biofeedback at the Britton Center up to the present time. At the present time, he is not working. He is on Lyrica, Cymbalta, trazodone, Zanaflex, Vicodin, and time-released morphine. He goes to the Britton Center monthly. He has a positive cough/sneeze effect. He is doing daily exercises. He has daily and constant low back pain aggravated by prolonged walking, standing, and lifting. He is made better by lying down and rest. He has left leg pain to his left calf. There is numbness down his legs to both feet. He uses a back belt full time. In the past, he has a history of elevated cholesterol. His jobs have included Alaska Trailblazing, underground sprinkler, truck driving, and cab driving. In his free time he enjoys gardening, T.V., and biking. In his review of systems he is treating for high cholesterol. He has no allergies. He has a negative family history for diseases. He smokes one pack of cigarettes a day. He does not drink alcohol. He has a high school education and two years of college. On examination, he is 5 feet, 11 inches and weighs 242 pounds. All motions were active. There was no passive range of motion. He was told to inform me of any acute increase in pain and he did not. He walks without a limp. He has 50 degrees of lumbar flexion, 20 degrees of lumbar extension, 45 degrees of right and left side bending, and 40 degrees of right and left rotation. Straight leg raising tests are negative in the supine position. Sensory examination of both lower extremities is normal. All the various motor groups of both lower extremities were tested and he has excellent strength. Reflexes at the knees and ankles are +1/+1 and equal bilaterally. There are no areas of acute tenderness. There is no evidence of spasm. 1. What medical conditions have you diagnosed? For each condition diagnosed, please state your opinion as to whether it is related to the work injury of July 17, In my opinion, Mr. Timothy Martin is postoperative left-sided L4-5 microdiskectomy with right-sided foraminotomy at L4-5 with use of operative microscope on December 14, He is also postoperative percutaneous endoscopic diskectomy at L4-5 on the left with blunt laminotomy. In my opinion, Mr. Martin sustained an L4-5 disk herniation on July 17, Both of the operative procedures are related to the work injury of July 17, 2006, where he herniated his disk at L4-5.

8 Page 8 2. The Alaska Workers' Compensation Act provides that an employer is not liable for palliative care after the date of medical stability unless the palliative care is reasonable and necessary (1) to enable the employee to continue in the employee's employment at the time of treatment, (2) to enable the employee to continue to participate in an approved reemployment plan, or (3) to relieve chronic debilitating pain. ("Chronic debilitating pain" is defined as pain that is of more than six months duration and that is of sufficient severity that it significantly restricts the employee's ability to perform the activities of daily living. "Palliative care is medical care or treatment rendered to reduce or moderate temporarily the intensity of pain caused by an otherwise stable medical condition, but does not include those medical services rendered to diagnose, heal or permanently alleviate or eliminate a medical condition.) In your opinion, is the current regimen of drugs palliative rather than curative in nature? If the treatment is palliative, does it meet any of the criteria listed above? In my opinion, the current regimen of drugs is palliative rather than curative in nature. In my opinion, the treatment does not meet any of the criteria listed above. 3. In your opinion, what medications are reasonable and necessary in relation to the work injury, and meet the criteria for palliative care listed above? Please be as specific as possible with regard to medications and dosages that you would recommend for this patient. The use of Cymbalta is a psychiatric medication and is outside of my area of expertise. In my opinion, the Lyrica, trazodone, Zanaflex, Vicodin, and time-released morphine are not reasonable or necessary in relation to the work injury and, in my opinion, do not meet the criteria for palliative care listed above. In my opinion, addicting a patient to narcotic medication and mood altering medication with chronic pain is not reasonable or necessary care nor is it palliative treatment. In these situations, addicting the patient to the medication becomes a worse problem than what was initially being treated. In my opinion, I would recommend Tylenol or other over-the-counter anti-inflammatory medications to be used on a p.r.n. basis. I do not believe he needs any narcotic or mood altering medications. He could take, for an anti-inflammatory, 600 mg of Motrin three times a day. He could take two Tylenol three times a day as long as it remains below the level of toxicity.

9 Page 9 4. Are there any other treatment measures, curative or palliative, besides medications that you would recommend for this patient on the basis of the accepted work injury? In my opinion, there are no other treatment measures, curative or palliative, besides medications that I would recommend for Mr. Martin on the basis of the accepted work injury. If you have any questions, please feel free to contact me. Sincerely yours, Raymond Corcoran, MD

HISTORY AND CHIEF COMPLAINT:

submitted by Keith M. Bartley, D.C. Jasper, IN 07/21/11 presented at Cox Seminar in Nashville, TN, on October 8 9, 2011 HISTORY AND CHIEF COMPLAINT: 01/21/11 55 year old male press operator for Jasper