February 13, 2004
Attorney name
Address
City, State Zip
Re: Your Requested Medical Report of CS
Date of Injury; December 1, 2001
Dear Mr. Attorney:
**** History of Occurrence ****
The above captioned patient was first seen at this office on September 12, 2003 stating he had been injured in a vehicular accident occurring on December 1, 2001. He was the seatbelted driver of his truck and had come to a stop even though he did not have a traffic stop sign to observe. Just as he started driving East through the intersection of Culver and 13th Ave and looking straight ahead, another vehicle’s driver was driving his car at a high rate of speed and failing to heed the traffic stop sign for his street at the intersection, ran into the side of Mr. Smith’s truck just behind the drivers door. This caused his truck to be immediately pushed sideways and tipped over onto its passenger side. Mr. Smith stated he had to crawl out of his driver’s door window to escape the vehicle.
During the impact of the accident the truck’s driver side door, which had a protruding arm rest, was shoved sideways to the right impacting Mr. Smith’s left shoulder, arm, elbow, chest/abdomen, pelvis, thigh, and knee. Due to the abrupt stopping of the forward movement of his truck followed by abrupt rotation of the rear of the truck 90 degrees to the right and the abrupt flipping of the truck onto it’s right side, he was initially thrown forward causing his chest to impact the steering wheel and his knee to impact the steering column and dash area. The truck then abruptly turned onto its right side causing Mr. Smith to be thrown to the right and hang by his seatbelt. In a panic Mr. Smith reports freeing himself from the seatbelt and falling to the passenger side door. He then had to turn himself around so that he could climb out of the driver’s side door.
**** History of Medical Care ****
Immediately following the accident he felt shocked. He declined to be transported to a hospital.
Prior to being seen at this office Mr. Smith was professionally seen by the following doctors. He was evaluated and treated but has not received treatment that has taken care of his sufferings.
On December 4, 2001 A.T. MD performed a cursory evaluation after making him wait 3 ½ hours in his reception/sitting room. His treatment was a prescription of Hydrocodone for pain.
From December 12, 2001 to about December of 2002 he was seen by Drs. F and D of U Chiropractic Clinic. Mr. Smith was diagnosed as having suffered from the following:
1. Sprain/strain injury of the cervical, thoracic, and lumbar spine regions
2. Segmental dysfunction fixations of the cervical, thoracic, and lumbar spine regions
3. Post concussion syndrome.
From January 17, 2002 to February 25, 2002 R.R. MD attended him. She ordered a MRI and a CT (with and without contrast) of the painful left upper abdominal/chest area that had been painful since the accident. Her treatment of Mr. Smith consisted of Zantac to control the muscular spasms in the left upper abdomen and lower chest region. She also prescribed Hyoscyamine sulfate 0.125mg, Methocarbanol 750mg, and Ranitidine 150mg for reduction of his symptoms.
Mr. Smith was referred by his chiropractic doctor at U Chiropractic to Dr. J.C. of S. Family Medicine - for evaluation of the pain that was associated with a slight swelling in his left upper abdomen just below the last rib and costal cartilage. Dr. C evaluated him on January 8, 2002 and prescribed medication to ease his pain. Mr. Smith stated he was afraid of what was happening in his abdomen since no one had as yet been able to give him a diagnosis or treat the problem except with pain prescriptions.
Mr. Smith made an appointment to be evaluated on August 16, 2002 by S. S. DO, family medicine. This evaluation was for the purpose of allaying Mr. Smith’s fear regarding taking an airplane flight with the abdominal problem with which he had been suffering since the accident. Following the evaluation Mr. Smith felt enough at ease to proceed with his plans to travel by air.
From October 1, 2002 through November 2002. Mr. Smith saw Dr. C of P Family Physicians who performed examinations, relative to the ongoing left upper abdominal pain, to determine if the injury had resulted in any identifiable internal pathology that could be identified. Dr. C then referred Mr. Smith to a gastroenterologist.
On November 14, 2002 Mr. Smith was seen by A. S. MD. Dr. S ordered x-ray diagnostic imaging of Mr. Smith’s colon using contrast media. The radiologist stated that the colon was slightly tortuous at the splenic flexure and the rectum might be narrowed. A sigmoidoscopy was suggested. Dr. S. performed the sigmoidoscopy to 60cm with normal findings of the lining of the colon. Of note is that Mr. Smith had 3 ½ days without any left upper abdomen swelling or pain following the colon x-ray study. The condition then gradually returned to the same level of intensity and location that had been symptomatic since the date of the accident.
**** Symptoms ****
Mr. Smith related that due to the accident he has suffered from neck pain, sharp pain in his left shoulder with limitation of movement, chest muscle spasms with pain on the left side just below his rib cage, low back pain, left and right top of hip pain, sharp pain in his lower right leg, pins and needles in his legs, upset stomach, fatigue, and irritability. The pain in his right leg is constant and sharp at this time. He also states that he has suffered loss of memory, diarrhea, headaches, no motivation, depression, fatigue, and he no longer drives his vehicle as much as he used to drive it due in part to the pain he feels in his right lower extremity.
The pains are aggravated by straining, stretching and twisting, and relaxing. He further states that moving around in bed is difficult. The pains are relieved by lying on his back when he is asleep and by using ice packs.
He further states that since the accident, the injuries he has have limited his home life activity, have made sleeping difficult, have limited his occupational work to light work, and his recreational life is “very very (sic) limited.” He has not been able to participate in contact sports or scuba diving.
About a month before coming to this office he experienced a paralyzing feeling in his lower back. He went to a hospital emergency department with this pain six days before presenting to this office for the first time, after it had become sharp and traveled down his right leg. At that time the pain was so intense that it prevented him from getting out of bed the night before he went to he hospital. Any movement he made was extremely painful like sharp jabbing knives. About a month before that he had a cold feeling with a slight twinge in his lower back while performing stretching exercises he had been prescribed to do for correcting his injuries.
He further stated that prior to the injuries of the accident and before he started experiencing the intense pains in his low back/pelvis and right lower extremity he could do the following physical activities. He could lift and carry tools and equipment around (110+ pounds) for several hundred feet around a job site and set it down at the new use site every day without fatigue. However, since the accident with its injuries he has only been able to lift 40 to 45 pounds without feeling pain, discomfort, or restriction of motion. He can carry this weight a very short distance or hold it for a short period of time and he can not do this daily due to the fatigue he feels. He is now limited in his lifting ability in that he can’t lift as high or reach out and lift as much or spread his hands and lift as much as he was able to do prior to the accident. When he does strain himself in this manner it causes pain that lasts for hours or days. He states he can only work for two hours standing or walking and only three hours sitting daily. He estimates this at 25% of his former work capacity physically and at 30% mentally.
He states that before he was injured in this accident he was able to do the following without limitation, difficulty, or pain. Since the accident he has suffered pain, weakness, and structural limitations doing all of the following. Since the recent increase in pain in his right lower extremity and low back all activities were changed and made even worse.
Walking - The shot and prescription medications from the emergency room doctor made the pain more bearable. When he had to walk it was painful and he was putting more weight on his left leg. He walked in the posture of a bent over injured man even though he was trying to walk as though he was pain free. He stated that he went to Home Depot to purchase a back brace and he distinctly remembers people staring at him like he was disfigured. He said, “I turned around to catch a few folks stealing a glance. Best I can describe the way I walked is the walk of the ‘elephant man’. Also, the more I walked the more tired I got. I could only take baby steps.” Running and climbing were severely limited due to the severity of pain in his back and right lower extremity.
Standing - He would lean against a building or object to take weight off his body’s right side. After a short time he would need to find a seat. He stated that after sitting for a while he sometimes likes to stand to stretch. However, with the pains he was feeling as a result of the accident injuries he stated that he did not want to stand at all.
Sitting - He stated this activity would become uncomfortable after a short time. Taking medications killed some of the pain but for the most part, he stated he had constant pain. He stated he would shift around in the chair to find a comfortable spot but usually he would end up lying down in bed.
Bending - Since he could not reach down to tie his shoes, he had to wear sandals. He had limited movement. He stated that because of the pain caused by bending, he had to limit his movement.
Stooping - When doing this he found he could not bend his right leg completely. Consequently, if he needed to stoop, his right leg would be positioned out to the side and kept as straight as possible to minimize the pain.
Lifting - This would affect his lower back by increasing the pain. He would shift his weight to reduce the stress that was put on his right side. He could feel the strain and the sharp pain whenever he lifted anything.
Pushing - He could only push with his arms. He stated that he had no power in his lower body to help him push because it was too painful. Pushing a lightly filled cart shopping cart was easiest since he could lean on it and take the weight off of his legs.
Pulling - The severe pain he felt in his lower back and into his right lower extremity limited his ability to pull with any degree of force. He could not get any leverage. He stated, “I try to plant the one foot and pull; the pain would come every time way before I could complete the pull.” He said that severe pain is the general theme.
Climbing - He stated that whenever the need came to climb stairs he would climb them by pulling himself up and stepping sideways one step at a time with both feet on each step.
Reaching - He stated that the more he reached out to grab something, the more his body would stretch. The more he stretched, the more he felt shooting pain down into the back and into his right lower extremity. Whenever he reaches out to lift something from off a shelf or from under a bed with his left arm or if he uses it to brace himself while he reaches with his right arm he feels a “sharp deadly pain” i.e. one that stays with him for up to 15 minutes and the rest of the day it feels like it has been pulled out of place.
Gripping - He states that he could not grip a pair of vice grips to tighten down on something. If he tried he would feel pain and then he could not really squeeze (grip) with the force needed to accomplish the task.
Kneeling - Any motion like this was very painful. This was very much like stooping in that if he could get into a kneeling position his right leg could only be bent slightly. If he got down into a kneel he would “lock-up”. Trying to get up would be much harder and much more painful.
Balancing - He stated, “When one of your legs feel that they are on fire you compensate by shifting your balance so you feel less pain. If I made a misstep or slipped on some surface I would fall down because it was much more painful to try and stop my movement.”
Fatigue - Any movement he made took lots of effort on his part to just limit the pain while moving. This was very stressful leaving him emotionally and physically exhausted. He is of the opinion that the fatigue is difficult for him to handle emotionally as it limits his every activity.
He states that he had not experienced any of the symptoms previously described, previous to the accident of 12-01-2001
**** Examination ****
Based on the history and related symptoms a clinical examination was performed on September 8 and 11, 2003 consisting of orthopedic, neurological and chiropractic methods. The following positive findings are commensurate with the mechanism of injury and explain his symptoms.
Palpation of his spine and paraspinal tissues revealed tenderness on spinal percussion of the occiput at the upper spinal region, C3, 4, 5, T6, 11,12, L1, and 5. Tenderness was present with a plus 2 intensity bilaterally at the level of occiput, C3, 4, left side only at 5, bilaterally at T6, 11, and left side L1, 2, 5, and Sacrum, right side was a plus 3 intensity at L1, 5, and sacrum. There was bilateral muscle splinting plus one intensity at the level of T6 and a plus two intensity at T11, 12, L1,2,5, and Sacrum. Edema was present at the level of T11 and 12.
Palpation of the left upper abdomen just below the costal cartilage/rib margin revealed swelling when he assumed various body postures. It was not possible to reproduce the swelling with a specific posture each time but was present with most forward and or left lateral flexion movement intentions intermittently.
Cervical range of motion was initially limited in flexion to 45 degrees from a normal of 60 degrees and on lateral flexion both left and right to 35 degrees with a normal of 40 degrees. Following the examination, the cervical range of motion was re-evaluated and it was found that additional limitation had occurred due to an increase in inflammation secondary to the spinal movement necessary to carry out the examination. Left lateral flexion was reduced to 20 degrees with a normal of 40 degrees and left rotation was reduced to 30 degrees with a normal of 60 degrees.
Muscle testing revealed his left neck flexors to be very weak and his right neck flexors to be weak.
Cervical compression testing brought a complaint of pain on the left side in the neutral head position and in the left head/neck tilt position and in the posterior flexion head/neck tilt position.
Wright’s test was positive on the left indicating compression of the axillary artery by the pectoralis minor muscle when his pulse was taken with his arm raised to extend above his shoulder and behind it.
The Codman Arm Drop Test was positive on the left. In this test his extended arm is raised to 90 degrees in abduction and the examiner strikes the arm downwards. It is positive when he is not able to hold his arm in position and may indicate a torn rotator cuff ligament.
Apley Scratch test was positive on the left. This test is for tendonitis and is performed by placing his hand behind his head for external rotation and reaching for his wallet for internal rotation of the humeral head in the glenoid fossa (shoulder joint).
Coracoid Push Button Sign test was positive on the left. In this test the examiner applies pressure to the subacromial bursa and if pain is felt by the patient it indicates possible presence of bursitis.
Dawburn’s Test was positive on the left. This test seeks to determine if the subacromial bursal pain of the Coracoid “push button” sign is relieved when the examiner applies firm pressure on the coracoid “push button,” the arm is raised to 90 degrees, and the deltoid covers the “push button.”
The shoulder Apprehension Test was positive on the left. This test is to determine is there is a dislocation of the shoulder. The patient’s arm is abducted and externally rotated by the examiner and if there is pain it may indicate a chronic dislocation of his shoulder joint.
Yergason’s test was positive on the left indicating a possible instability of the biceps tendon in the bicipital groove. In this test the examiner rotates the patient’s hand posteriorly while holding the elbow in a state of 90 degree flexion and close to the patient’s torso.
Cozen’s Tennis Elbow Test was positive on the left. The examiner stabilizes the patient’s forearm, the patient makes a fist and posteriorly flexes (extends) the wrist, the examiner then attempts to force the fist towards the anterior position (flexion) while the patient resists. The test is positive when there is pain at the lateral collateral ligament.
His elbow was further tested for ligamentous stability by stabilizing his elbow and holding his wrist then forcing his forearm medially and laterally. He had gapping of the bones of the elbow on both medial and lateral side position indicating relaxed muscle and or ligamentous tissue.
Pinwheel (sharp) testing of the dermatomes of his upper extremities revealed a hypoesthesia of the C-5 dermatome on the left.
Phalen’s Test for Carpal Tunnel syndrome was positive at the left wrist. In this test the wrists are hyperflexed against each other and held for 60 seconds. It is a positive test when paresthesia (abnormal nerve sensation) is felt in the hand and fingers.
The Radial Nerve test was positive on the left.
O’Donahue Maneuver testing of the torso in isometric rotation against testor resistance was reported to be painful on the left indicating positive reaction for joint tissue swelling.
The Tripod test where the patient is seated and asked to extend each leg one at a time was positive for pain in the sciatic tract when the right leg was extended.
Minor’s Sign where the patient is seated and asked to rise from the seated position was positive for pain on the right side of the lower back.
Kemp’s test where the patient is asked to stand folding their arms across their upper anterior torso and bend obliquely backwards, was positive for pain when bending to the right side. This indicates swollen joints in the back.
Trendelenburg test is where the patient is asked to stand on one lower extremity (leg) and lift the other leg, flexing at the hip and the knee. If the iliac crest (pelvic rim) of the lifted leg fails to rise, the indication is weak gluteus medius muscle on the standing side (opposite buttocks). He was positive for the left gluteus medius being weak.
Reported pain during palpation of the sciatic nerve at the sciatic notch of the pelvis when the hip is flexed indicates some sort of space occupying lesion that the sciatic nerve is being pulled over in a lumbar intervertebral foraman. He was positive with palpation of the left sciatic nerve.
The forced leg lowering test evaluates for muscle weakness of the hip flexor muscles. The lower extremity is tested in the fully extended position with the patient supine. The patient is asked to raise the extremity to about 30 degrees flexing at the hip. The examiner then applies a downward pressure with the patient resisting. He was weak on the right.
Lasegue’s test with the patient supine is where the lower extremity is raised in the extended position flexing at the hip. If pain is felt along the sciatic nerve trajectory or diffusely over the hamstring muscle the test is positive. He was positive on the right for sciatica.
Braggard’s test with the patient supine is where the lower extremity is lowered approximately one inch from the position of pain during the Lasegue’s test and the foot is dorsiflexed. A positive test is a recreation of the pain in the sciatic nerve experienced during the Lasegue’s test. He was positive on the right.
Fajersztajn’s test with the patient supine is similar to the Braggard’s test except the well leg is raised and a positive is for pain to occur in the “sick leg”. He was positive for pain in the right lower extremity.
Homan’s test with the patient supine is to raise the straight leg to 30 degrees and dorsiflex the foot. A positive test elicits pain in the calf muscle region and may indicate thrombophlebitis or other soft tissue inflammation. He was positive on the right. In his situation the indication is for generalized reduction of drainage of lymph allowing an increased quantity of metabolic waste that is inflammatory to healthy cellular structures.
Hoover’s sign is to stabilize the calcanius (heel bone) of the patient’s good leg while the patient is in the supine posture. The patient is then asked to raise the opposite leg. A positive test is when there is no downward pressure on the good leg heel when the symptomatic leg is raised. This would equal malingering (Feigning illness or disability to escape work, excite sympathy, or gain compensation. Stedman’s Medical Dictionary 1982). However, when Mr. Smith raised his bad right leg a downward pressure was felt of the left heel. This test indicates no malingering was present.
Patrick’s Flexion-Abduction-External Rotation (Faber) test with the patient supine is when the thigh is flexed on the pelvis, the leg is flexed on the thigh, the lower extremity is then rotated laterally to bring the knee toward the plane of the surface laid upon. A positive test is when the patient complains of pain in the hip joint region during this test. He was positive on the right side.
Laquerre’s test with the patient supine is when a patient with a positive Patrick’s Faber test has their femoral head forced into the acetabulum by the examiner. When pain is felt in the joint the test is positive. Mr. Smith was positive on the right.
Manual muscle strength testing of the piriformis muscle on the right showed it to be weakened.
Testing of the dermatome distribution of the lower extremities indicated hypoesthesia paresthesia of the right lower extremity on its lateral aspect in both the thigh and leg.
Clonus testing with the patient supine is when the foot is dorsiflexed on the leg. A negative test is when the flexor muscles relax normally by decreasing their contractions in a smooth sequential manner as the foot is dorsiflexed. A positive test is when the muscles innervation is adversely stimulated by a lesion in the spinal cord or brain there is irregular relaxation of the muscle’s contractile ability and a rapid bouncing of the foot is felt. He was positive on the right.
With the patient supine the ability of the first toe to remain dorsiflexed when a force is applied to straighten it is a test for L5 nerve root malfunction. His right toe was weak when tested in this manner.
Lhermitte’s sign with the patient supine is performed like the Soto-Hall test. However, a positive test is when electric-like shocks are felt down the arms or legs indicating spinal cord compression by a lesion. He was positive for right lower extremity shocks.
Thomas Test is with the patient supine and the thigh is flexed onto the abdomen. It is positive when the opposite leg lifts off the table indicating tight hip flexor musculature. He was positive for right hip muscle tightness.
Gaenslen’s test with the patient supine is when the patient is asked to move to the side of the examining table and allowing the leg next to the edge to hang off the table while grasping the shin of the opposite leg with outstretched arms, flexing the leg upon the thigh and flexing the thigh upon the abdomen toward the chest. He experienced pain in the right lower back to include the right pelvis and right lower extremity when it was lowered off the edge of the table. The left lower extremity did not cause his to report pain. This is a test for malingering and Mr. Smith was shown to be truly suffering as he had stated previously therefore this test indicates no malingering was present.
Ober’s test with the patient lying on each side alternately is when the patient’s leg is lifted lateral to their body, the opposite leg has its knee flexed to allow the patient to maintain balance easier, and then the leg that is lateral to the patient’s body is released by the examiner. If the leg remains elevated and can’t be easily lowered, the indication is a tight iliotibial tract due to hypertonic tensor fascia latae muscle. His right side was positive.
Ely’s test with the patient prone (lying face down) is performed by flexing the heel of one lower extremity to the opposite buttocks and lift the thigh off the table. A positive test is when pain is felt in the sacroiliac joint on the side being tested by the examiner. Mr. Smith was positive with pain in the right sacroiliac joint region on right lower extremity testing.
Yeoman’s Femoral Stretch test with the patient prone is performed in a similar manner to Ely’s test except the heel is brought to the same side buttocks. If pain is felt, it indicates a lower lumbar intervertebral lesion on the same side. Mr. Smith was positive with pain on the right side.
The Achilles Reflex test was performed with the patient prone and the feet extending toward the floor off the end of the examining table. His right reflex was depressed in response.
Manual muscle strength testing showed both the gluteus maximus and hamstring muscles to be weak in the right lower extremity.
He complained of pain in his right lower extremity on testing the knee range of motion, McMurray’s test, Apley’s compression and traction testing, as well as the drawer sign test.
Based on the history and clinical examination findings, x-rays of the spine were ordered. Findings are commensurate with the mechanism of injury.
X-RAY STUDY TAKEN 9-12-2003
CERVICAL SPINE
Examination of the cervical spine in the sitting posture reveals a straightening of the upper 5 vertebrae from the normal lordotic curvature.
The posterior inferior margin of C5 is 5mm posterior to the posterior superior margin of C6 in the neutral lateral view. The posterior flexion movement of the cervical spine does not increase the displacement. The anterior flexion movement of the cervical spine reduces the displacement to 0mm. This 5mm of movement results in instability of the joint structures.
Posterior flexion of the cervical spine results in a movement of C4 in relation to C5 with an increase of the intervertebral disc superior margin anteriorly in relation to the inferior margin. This is abnormal movement. The neutral lateral disc angle is 5 degrees. The posterior flexion disc angle is 13 degrees. The anterior flexion disc angle is 1 degree.
Posterior flexion of the cervical spine results in a movement of C5 in relation to C6 with an increase of the intervertebral disc superior margin anteriorly in relation to the inferior margin. This is abnormal movement. The neutral lateral disc angle is 10 degrees. The posterior flexion disc angle is 13 degrees. The anterior flexion disc angle is 3 degrees.
The occiput exhibits normal movement in posterior flexion but has no movement in anterior flexion.
Osteophytosis of the joints of Luschka is noted bilaterally at C5-6 with slight encroachment into the intervertebral foramen.
The odontoid neutral, right head leaning, and left head leaning views reveal the odontoid projection of the axis bone, the cruciate and alar ligaments, and the ring of the atlas to be intact.
There is leaning of the cervical spine above T2 with C3 aligning 5mm to the right. There is slight roughening of the bone silhouette indicating osteophytic overgrowth on the medial margins of the alar processes of C6.
Left face rotation is performed and the vertebrae are in normal vertical rotational relationship. Right face rotation is performed with the cervical spine leaning to the right during rotation.
THORACIC SPINE
Examination of the recumbent thoracic spine reveals the following findings.
The kyphotic curvature is within normal limits. However, their appears to be a 5mm anterior wedging of the bodies of T7, 8, 10, 11 and a 10mm anterior wedging of the body of T12. T4 has a 3mm anterior wedging and T6 has a 2mm anterior wedging of the vertebral body.
The thoracic spine ascends cephalward above the lumbar spine within normal limits to the level of T7. T7 has a vertebral body height differential with the left side being 2mm less than the right side. T3 has a vertebral body height differential with the right side being 2mm less than the left side. The spine’s cephalward ascent is modified with slight lateral leaning above each of these vertebrae
The disc spaces appear relatively equal and within normal limits throughout the thoracic spine region.
The inferior vertebral body margins of T5 and T6 have distinct nucleous pulposis indentations that are not visualized on the other vertebral bodies.
LUMBAR SPINE
Examination of the lumbar spine in the recumbent posture reveals the following findings.
Vertebrae in their ascent from the pelvis to the thoracic spine are spinous process aligned except for L2 and 3 which have spinous processes that are shifted left 3mm from the midline. These vertebrae are also left posterior rotated. Their rotations are L5 - 0mm, L4 - 6mm, L3 - 8mm, L2 - 7mm, L1- 7mm, and T12 is 3mm.
The lateral view shows a straightened lumbar lordotic curvature with the L4-5 and L5-S1discs making up the bulk of the curve. The sacral base angle is 48 degrees.
There is osteophytic lipping of the anterior margins of T12 and L1. The anterior superior margin of L2 also has osteophytic lipping.
FULL SPINE POSTURAL STUDY
Examination of the full spine in the standing posture reveals the following findings.
There is a 9mm inferior left femoral head in relation to the right femoral head. The inferior margin of the symphysis pubes joint is 5mm wide and the superior margin is only 2mm wide. The iliac crests show the same left 9mm left inferior tilt. The lumbar spine leans 8mm to the left as it ascends cephalward from the sacrum to L3. The spine then compensates with an 8 mm lean to the level of T8. The spine then ascends with a 6mm lean to the left to the level of T2. The spine then ascends vertically without compensatory leaning up to include C6. C5 is tilted inferior on the right and the cervical spine ascends with a 10mm lean to the right to the level of the foramen magnum of the occiput.
The lateral projection reveals a 55 degree sacral base weight bearing angle. The lumbar lordotic curve is reduced. The thoracic kyphotic curvature is flattened in the mid region. The cervical lordotic curve is absent.
The 8 degrees of increased movement that occurs between C4 and C5 is due to tearing forces generated by the weight of his head pulling on his cervical spine with this accident’s mechanism of injury.
COMPARISON X-RAY STUDY WITH 09-12-2003 STUDY
CERVICAL SPINE
Examination of the cervical spine reveals a reduction of the posterior malposition of C5 in relation to C6 from 5 to 3mm. The posterior flexion study also shows a reduction in instability from 5 to 3.5mm and the C4-5 disc angle is increased from 13 to 15 degrees with C5-6 to 17 degrees.
The vertical height of the cervical spine from the first thoracic vertebrae to the occiput has been increased by 4mm.
The left face rotation view’s vertebral movement appears considerably more equal to the right face rotation’s vertebral movement.
Thoracic Spine
The findings appear relatively unchanged when compared to the study of 9/12/2003.
Lumbar Spine
The findings appear relatively unchanged when compared to the study of 9/12/2003.
COMPARISON X-RAY STUDY WITH 09-12-2003 FULL SPINE POSTURAL STUDY
FULL SPINE POSTURAL STUDY AP and LATERAL VIEWS.
Examination of the full spine to include the pelvis reveals the cervical spine to ascend cephalward without the previously seen right leaning. The thoracic/costal spinal alignment and the lumbar spinal vertebral alignment do not appear changed from the 09-12-2002 study.
X-rays taken elsewhere were reviewed.
Diagnosis
Based on the current history, clinical examination and x-ray findings the following diagnoses were made:
1. Hyper lateral flexion traumatic injury to the cervical spine with neurovascular and myofascial inflammation. (International Classification of Diseases 9th Revision [ICD-9 #847.0) (Moderate late effects ICD-9 #905.7)
2. Traumatic injury to the thoracic spine with neurovascular and myofascial inflammation. (ICD-9 #847.1) (moderate late effects ICD-9 #905.7)
3. Traumatic injury to the lumbar spine with neurovascular and myofascial inflammation. (ICD-9 #847.2) (moderate late effects ICD-9 #905.7)
4. Occipitocervical multiple segmental fixation dysfunction (ICD-9 #739.0) (moderate late effects ICD-9 #905.7)
5. Cervical Spine multiple segmental fixation dysfunction (ICD-9 #739.1) (moderate late effects ICD-9 #905.7)
6. Thoracic spine multiple segmental fixation dysfunction(ICD-9 #739.2) (moderate late effects ICD-9 #905.7)
7. Lumbar spine multiple segmental fixation dysfunction(ICD-9 #739.3) (moderate late effects ICD-9 #905.7)
8. Bilateral sacroiliac joint segmental fixation dysfunction(ICD-9 #739.4) (moderate late effects ICD-9 #905.7)
9. Costovertebral multiple segmental fixation dysfunction (ICD-9 #739.8) (moderate late effects ICD-9 #905.7)
10. Nonallopathic lesion abdomen (ICD-9 #739.9)
11. Partial dislocation C5 on C6(ICD-9 #839.03) (Moderate late effects ICD-9 #905.7)
12. Sacroiliitis ((ICD-9 #720.2) (Moderate late effects ICD-9 #905.7)
13. Sciatica (ICD-9 #724.3) (Moderate late effects ICD-9 #905.7)
14. Left shoulder sprain (subscapularis [muscle]) (ICD-9 #840.5) (Moderate late effects ICD-9 #905.7)
15. Left shoulder sprain (coracoclavicular (ligament)) (ICD-9 #840.1) (Moderate late effects ICD-9 #905.7)
16. Carpal tunnel syndrome (ICD-9 #354.0) (moderate late effects ICD-9 #905.7)
Prescribed Treatment
Based on the diagnoses, a treatment regimen consisting of manual musculoskeletal structural manipulation, axial thrust with vectored force traction thrust, and physical therapy to include acupuncture, massage, infratonic radiation was instituted. I prescribed Vicodin, 10mg hydrocodone and 660mg acetaminophen, to relieve the pain he was reportedly suffering from in his spine and lower extremity until the manipulative treatments could be effective in reducing the accumulated tissue metabolic wastes.
He was urged to eat a diet consisting of raw or steamed vegetables, lean meat such as skinless chicken or fish, and drink at least 8 glasses of water per day. It was strongly suggested that he not eat foods with preservatives, artificial flavoring and coloring agents, and a high store shelf life. He was further urged to continue with his exercise regime to the extent possible in his life.
DISCUSSION
It should be noted that the cervical spine can withstand a large amount of force when applied in the straight front to back or back to front planes of movement. When the force is applied laterally the cervical spine can withstand a moderate amount of force. However, when the face/cervical spine is rotated 45 to 50 degrees the movement occurs chiefly at the atlanto-axial joint accounting for about half of the total cervical spine rotation ability in a normal, non previously traumatized spine. If the body is then pushed suddenly and unexpectedly forward the neck is pulled into posterior flexion and extension as it begins to move the head. During consequential head rotation, because the vertebral artery is fixed at the first and second transverse cervical foramina, it is stretched, compressed and torqued. Reduction of the vertebral artery flow due to cervical spine rotation especially during posterior flexion movement has been well documented. In fact this is the preferred result of a solid landing uppercut punch in boxing that results in a knockout due to vertebral artery trauma and subsequent spasm depriving the brain of needed blood flow. If the blow is severe enough, based on the individual’s health/disease condition of the artery, the artery will tear and the person will stroke and possibly expire.
The vertebral arteries climb the cervical spine through openings (foramen) in the transverse processes. After emerging from the transverse foramen of the atlas, the vertebral arteries proceed to wind posteriorly and medially around the lateral mass of the atlas, to pass via a groove in the posterior arch of the atlas, between the atlanto-occipital joint capsule anteriorly and the posterior atlanto-occipital membrane posteriorly.
The vertebral arteries then pass through the foramen magnum and, at the lower border of the pons, unite to form the basilar artery. The basilar artery passes up the anterior surface of the brainstem and divides to become the posterior cerebral arteries.
The posterior inferior cerebellar arteries, the largest branches off the vertebral arteries leave the vertebral arteries just before the vertebral arteries join each other to form the basilar artery. The posterior inferior cerebellar arteries run a tortuous course along the lateral part of the medulla, to which they are the main blood supply. In some cases the vertebral arteries may terminate in the posterior inferior cerebellar arteries.
Research indicates that rotation is the single most effective movement producing a decrease in blood flow of the vertebral artery. Therefore compression or spasm of a vertebral artery from either the first or second cervical foramen during rotation will induce symptoms especially if compounded by posterior flexion and then by anterior flexion of the motor unit. Anterior and posterior are used to denote movement of the body forward and backward in relation to the vehicle’s impact moment of force and not anterior or posterior to the face’s rotational position.
Normally, during daily head movements, occlusion due to compression does not produce a decrease in flow enough to produce ischemic signs and symptoms, or the development of infarction. In most cases the development of infarction indicates an underlying arteriopathic process, other than brief occlusion.
The time between the application of trauma in the onset of ischemic symptoms and signs can vary from immediately to several days later. The interval is probably related to the mechanism of injury. When brainstem ischemia is due to vasoconstriction, symptoms would be expected immediately; whereas those (other than the pain of dissection) due to thrombus and/or embolus formation resulting from a vessel wall dissection and/or vessel occlusion would only become symptomatic after some time.
A review of 183 cases of vertebral artery flow restriction post vertebral artery injury reveals that the time between trauma and the onset of symptoms was given in 136 of the cases (74%).
Analysis of the 136 people’s onset of symptoms showed the percentage of them in which symptoms began in each of the following time frames:
1. 69% during trauma
2. 3% within moments or minutes of trauma
3. 9% within one hour of trauma
4. 8% 1 - 6 hours after trauma
5. 5% 7 - 24 hours after trauma
6. 6% 24 hours or more after trauma
Signs and symptoms of vertebrobasilar ischemia produced by trauma usually occur immediately.
The major signs and symptoms of vertebrobasilar ischemia are as follows:
1. Dizziness/vertigo/giddiness/light headedness
2. Drop attacks/loss of consciousness
3. Diplopia (or other visual problems/amaurosis fugax)
4. Dysarthria (speech difficulties)
5. Dysphagia
6. Ataxia of gait (walking difficulties/incoordination of the extremities/ataxia/falling to one side)
7. Nausea (with possible vomiting)
8. Numbness on one side of the face and/or body
9. Nystagmus
Dizziness is the most common symptom of vertebrobasilar ischemia and may be unaccompanied by any other symptom or sign.
An understanding of the mechanisms involved in the production of head and/or neck pain due to trauma of the nerves in the pain sensitive vessel wall, or ischemic signs and symptoms due to decreased blood flow to the brainstem at the time of trauma indicates why the spine should be properly treated if signs and or symptoms develop.
It is also important to understand the pathological effect of trauma to the individual nerve cell axons, dendrites and cell bodies. Studies on experimental ischemia and compression of peripheral nerves concluded that any trauma to a nerve trunk may induce microvascular injury in the nerve. A slight trauma may cause epineurial micro-bleedings, edema, etc. Severe trauma which may be defined as prolonged pressure injury to endoneurial capillaries (blood-nerve barrier) leading to intrafascicular (space between the pathways of nerve fibers in the spinal cord) resulting in edema. The establishment of post-ischemic or post-traumatic intrafascicular edema coincides in time with severe disturbances in nerve function.
In other studies graded compression was applied directly to exposed nerve trunks by means of a “mini-cuff”. It was found that 2 hours of compression with 200 to 400 mm Hg induced break-down of the blood-nerve barrier. Local nerve compression with pressures of 50 to 400 mm Hg acutely blocked anterograde nerve cell axonal transport in sensory vagal nerve fibers. Reversal of transport blockade generally occurred within a day after compression at 50mmHg; with higher pressures recovery occurred in most cases within one week. The duration of the transport blocks was related to the magnitude (time and force) of the pressures applied.
The effect of the force of the accident impact trauma to Mr. Smith’s nervous system was amplified by the rotation of his face/head to the right. His initial and ongoing symptoms are explained by this traumatic pathologic effect not only on his intra-joint structures but also on the small muscles and ligaments of the inter-joint structures and the proximal neuronal and vascular structures including the pons, medulla oblongata and the posterior brain centers of vision interpretation, balance, and hand/eye coordination.
Research studies have shown that rotation of the face to the right or left and posterior extension of the head has more effect on narrowing the opening of the vertebral artery than anterior or posterior flexion in the face forward (non-rotated) posture.
Researchers have found that whiplash biomechanics causes injury to the spinal disc and facet joints.
The spinal disc and facet joints are the most probable source for the initiation of the perception of chronic cervical, thoracic, and/or lumbar spine whiplash pain and related dysfunction .
An appreciable amount of chronic pain afferent nerves synapse in the limbic cortex. Their constant stimulation causes an abnormal psychological profile in response to the chronic pain being suffered. This abnormal psychological profile can only be helped by successful treatment of the chronic pain.
The best treatment for the spinal disc and facet soft-tissue and bone joint surface cartilage injuries is early, persistent, controlled motion of the injured tissues allowing full circulation of blood and drainage of lymph.
Self directed controlled motion of injured extremity joints is possible because the muscles that cross those joints are primarily under the control of the voluntary motor cortex.
Self directed controlled motion of injured spinal joints is not possible because the muscles that move the individual segments are not under the primary control of the voluntary motor cortex. They are controlled primarily through the vestibular spinal tracts (descending medial longitudinal fasciculus), which is non-voluntary.
Injury to the spinal disc and facet joints causes a non-voluntary contraction of the non-voluntary segmental movers (primarily the multifidus muscle) at the level of injury and for several segments above and below the level of injury.
This non-voluntary contraction locks the motor unit into a certain parameter of position and reduced movement.
This reduction of movement causes the following chain reaction:
1. Opens the pain gate which impairs the “disc pump”
2. Acceleration of disc degeneration and increased disc acidity.
3. An increased firing of disc nociceptor nerve fibers
4. Alteration of the quality of the synovial fluid
5. The reduction of synovial fluid nutrient value
6. Development of posterior joint arthrosis and pain.
Naturopathic manipulative medicine applied to the injured musculoskeletal structures does the following:
1 Segmentally fires high threshold mechanoreceptors that di-synaptically inhibit tone in the segmental spinal motor unit movers, which improves segmental spinal motion and position.
2 This controlled movement allows the injured tissues to heal better and quicker.
3 This controlled movement improves the fluid exchanges of the disc and synovial fluid, which reduces pain and joint degeneration.
4 This controlled movement initiates a neurological sequence of events that causes pain inhibition (closes the pain gate).
The metabolic waste removal occurs by increasing the lymph fluid drainage of the interstitial fluid which allows room in the interstitial cellular spaces for more of the liquid content of the blood (plasma) to be released from the capillaries. This exchange of metabolic waste fluid with new interstitial fluid that contains nutrients with which the tissues can begin the process of healing the injuries caused by the accident is essential for tissue healing.
Mr. Smith stated that during the first three or four weeks following the beginning of treatment at this office he was in constant pain in his right lower extremity. He would take a Vicodin before he came to this office for treatment because he genuinely needed to ease (reduce/limit) the pain. The only time he was really without pain was when he was sleeping. However, he was only able to sleep a couple of hours at a time. He would then get up, move around, try to ease the pain and then would be able to sleep another couple of hours. Eventually his right lower extremity pains reduced greatly. He stated that for the longest time he had been wondering to himself and he thinks probably out loud occasionally, “HOW COME AND HOW LONG WILL I HAVE THIS VERY UNCOMFORTABLE NAGGING PAIN. DON’T THESE PEOPLE AT COMREHENSIVE HEALTH SERVICES REALIZE THAT WHEN I COME HERE AND GO BACK HOME I WILL STILL BE IN CONSTANT PAIN. CAN’T THEY DO SOMETHING THAT WILL MAKE THIS PAIN GO AWAY TODAY.”
As time passed following the initiation of treatment the pain in his right leg lessened. He could quantify the improvement on a weekly basis.
Comparative examinations to evaluate progress were conducted on October 7 and 8, 2003 and January 29 and 30, 2004. Progress has been documented. He has decreasing inflammatory responses and increased range of motion in the affected joint structures.
He has had several episodes of exacerbation of symptoms commensurate with his activities of daily living. These have been addressed appropriately with his regular prescribed treatment.
He has recovered much of the pre injury function of his body. However, it is important to understand the significance of Mr. Smith’s injury.
In recent years, the micropathology of acute soft tissue trauma has been thoroughly researched. Healing of ligaments and soft tissue injuries has been shown to occur by fibrous repair (scar tissue) and not by regeneration of the damaged tissue. The pathological process of healing has been classified into 3 phases:
1. Acute Inflammatory Phase (Reaction Phase):
Demonstrated by swelling, redness, warmth and pain.
This phase may last up to 72 hours.
2. Repair Phase:
The repair of the tissue begins after the swelling goes away. Once begun, collagen fiber synthesis may continue up to 6 weeks.
3. Remodeling Phase (Regeneration Phase):
The period during which the collagen (in the cells) is remodeled to increase the functional capacities to withstand the stress imposed on it. This phase may last up to 12 months or more.
The remodeled tissues; however, are deficient both in content and quality in the following respects.
1. The fibrotic repair of the once injured tissues leaves those tissues permanently weaker;
2. The fibrotic repaired tissue is always less elastic than normal uninjured tissues; and
3. The once injured tissues have an anatomical increase in the number of neurofibrils in them, leaving them permanently more sensitive to the normal stresses and strains of daily activities.
In a person who has suffered with traumatically induced acute inflammatory response chronically, it is important to note that the stress response evokes elaborate mechanisms by which they are able to survive and function in the hostile world. The major categories of human protective mechanisms include: physical barriers (e.g., skin), stress reactions, immune responses, inflammation, coagulation, chemical detoxification, and a widespread network of phagocytic cells in the reticuloendothelial system. The host, rather than using these modalities independently, responds to all injuries at the molecular level with a concerted constellation of host responses referred to collectively as the stress response. This response is most commonly seen in people following a number of inflammatory stimuli including: infection, trauma, burns, tissue infarction, immune-related diseases, and surgery. Characteristic changes occur involving the metabolic, endocrinologic, neurologic, and immunologic bodily functions.
Most of these changes are observed within hours or days after the onset of injury. They represent a series of local and systemic responses designed to aid survival by neutralizing the offending agent and restoring normal tissue functioning. These responses represent a major adaptive phenomenon whereby homeostasis is maintained in an altered steady state. Complete recovery occurs by a return to the normal steady state.
In general, the magnitude of the stress response is related to the severity of the injured state. In cases of major injury, survival occurs only if these interactive defense responses are sufficient to compensate for the imposed stresses. Host factors are important in determining individual survival. These include: nutritional status, immune status, age, gender, and concomitant disease. In many cases the return to the normal steady state can be unsuccessful, in that normal homeostasis is not achieved. Stress response changes can persist long enough that they also cause damage (e.g., chronic inflammatory disease such as rheumatoid arthritis or osteodegenerative arthritis).
In Mr. Smith’s case, the injuries have resulted in significant morbidity.
Therefore, Mr. Smith’s continuing symptoms are explainable due to the type of injuries he experienced during the accident. With the best of care he can be expected to experience periodic symptomatic exacerbations of his initial and subsequent post-trauma complaints caused by increased stresses and strains brought about by his various work and daily activities.
IMPAIRMENT
Utilization of the Fourth Edition AMA Guides to the Evaluation of Permanent Impairment the following is deduced:
Retrolisthesis with loss of motion segment integrity at C5-6 equals 25% impairment of whole person.
Right sciatic radiculopathy equals 10%.
When the effects on activities of daily living are added there is an additional 25 to 50% to be added to the above. I estimate, based upon the patient’s reported inability to carry out normal activities, that he is at a 35% level.
Due to his injuries, he now fits the AMA criteria for a 70% whole person permanent impairment rating.
PROGNOSIS
It is probable that Mr. Smith will experience periodic symptomatic exacerbations of his initial post-trauma complaints caused by increased stresses and strains brought about by his various work and daily activities.
These exacerbations can be controlled and his symptoms minimized by reapplication of the previously prescribed, medically indicated, and patient stated effective treatment of naturopathic manipulative medicine procedures and techniques. That treatment is best complimented with the presenting ‘body abnormality appropriate’ physical medicine modalities such as but not limited to specific exercise, massage, electrical muscle and nerve stimulation, traction, cold and heat, diathermy, and ultrasound. Acupuncture may be appropriate to use for re-directing the sensory input to his central nervous system affording him non-pharmacological pain/discomfort relief. Drug therapy including pain relief and neutraceutical medications will be prescribed as his condition warrants.
An example of an aggravation is the following.
“Just this past week (February 6 to 13, 2004) I have had to force myself to work longer and harder in my house remodeling business. The bulge below the ribcage on the left side of my chest became much more pronounced (became much larger). The bulge remained much longer and it felt much harder. It is a little frightening and a bit unnerving imagining what is going on inside of me.
Usually I follow Dr. Gear’s program trying to get proper rest by taking things easy and letting the body heal.
It very much scares me to think what will happen if I push to work harder and longer! Since day one I always described it as an “alien” coming out of my chest. Could it burst? Could it block the flow of something important? I have been refraining from vigorous activity because of the accident. Will I be able to travel, play sports, trek, scuba diving, and have a rigorous (or normal) sex life again, or will I have to worry, worry, worry.”
It is medically probable that this care will need to be provided at three times per week for the next eight months, two times a week for the following 12 months and one time a week for the following year in order to bring him to a stationary asymptomatic state such as he was experiencing prior to this injury episode.
All opinions contained in this report are given to a reasonable degree of medical probability.
If I can be of further help to you please contact me.
Sincerely,
Treating Physician
Comprehensive Health Services, Inc.
References for this report come from the following sources.
The Ciba Collection of Medical Illustrations, Frank H. Netter MD, CIBA Pharmaceutical Company, division of CIBA-GEIGY corporation
“Acute soft tissue injuries - A review of the literature”, John Kellett, Medicine and science in Sports and Exercise, Vol. 18, No. 5, pp. 489-500 (1986).
Vertebrobasilar Stroke Following Manipulation, Allan G. J. Terrett, Faculty of Biomedical and Health Sciences RMIT University, Bundoora Australia, 1996
Foundations for Osteopathic Medicine, Robert C. Ward et. al., Williams & Wilkins, 1997
The Neurobiologic Mechanisms in Manipulative Therapy, Irvin M. Korr, Plenum Press, 1977
Managing Low back Pain, William H. Kirkaldy-Willis MD, Churchill Livingstone, 1988
A Clinical Guide to Neuropathic Pain, Bradley S. Galer, MD and Robert H. Dworkin, PhD, McGraw-Hill, 2000
Guides to the Evaluation of Permanent Impairment, Fourth Edition, American Medical Association, 1993
Whiplash Overview Lecture Notes, Dan Murphy DC, International Chiropractic Association , 2002