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HomeMy WebLinkAbout2020CV30363 - Stuward Cross And Katrina Richman V. City Of Fort Collins - 034A - Exhibit A - Hugues Report Re Cross 4 W. Dry Creek Circle, Suite 135 | Littleton, CO 80120 Office: 303-798-1210 | E-fax: 303-997-2147 office@hughesmedicalconsulting.com CASE REVIEW Patient Name: Stuward Cross Date of Report: July 26, 2021 Date of Injury: June 7, 2017 Date of Birth: January 13, 1977 REVIEW OF HISTORY AND CLINICAL COURSE: Mr. Cross is a 44-year-old male, former taxi driver, whose medical records have been forwarded to me for the purpose of case review by his attorney, W. Clayton Harris. He has outlined issues for today's case review in his letter of July 13, 2021. Overall, today's case review is in rebuttal of a report submitted by Lloyd Thurston, D.O., who reviewed Mr. Cross' records as outlined in his report of July 5, 2021. Records pertaining to the motor vehicle collision begin with the traffic accident report of June 7, 2017. There is documentation that Stuward Cross was driving a 2010 Ford that was struck from behind by another vehicle. He and his passenger were not listed with injuries or transported for emergency medical evaluation. I reviewed a supplemental statement provided by Mr. Cross to police officer R. Finkle at the time of the collision. He noted that he saw traffic start moving and that he passed in front of the truck with the truck hitting the back passenger corner of his taxi cab. Mr. Cross testified by deposition on May 27, 2021, that after the motor vehicle collision, he developed symptoms of his feet cramping up and that “the focus was the pain in my lower neck and leading to my left side” per page 27. Medical records begin with notes from Concentra, beginning June 13, 2017. He was assessed then by physician assistant Amber Payne, who noted that Mr. Cross was involved in a work-related motor vehicle collision with onset of cervical and thoracic spine regional pain. She recommended x-rays of the cervical and thoracic spine, and these were done on June 13, 2017. In the cervical spine, no acute cervical spine fractures were seen and similarly, there were no fractures in the thoracic spine region noted by Vincent Lombardi, M.D. Physical therapy was initiated and I reviewed Mr. Cross' pain diagram from June 21, 2017. This diagram outlined symptoms of stabbing pain over the posterior aspect of the neck with burning pain inferior to that in the upper thoracic spine region. Burning pain was also noted in the left shoulder with pins and needles in the region of the left elbow. 1 SERVED ONLY: July 30, 2021 4:48 PM FILING ID: BB5F275FA148F CASE NUMBER: 2020CV30363 Exhbit A - Page 1 INDEPENDENT MEDICAL EXAMINATION Stuward Cross July 26, 2021 Page 2 Physical therapy notes document persistence of neck and thoracic spine pain. Massage therapy was then initiated on October 11, 2017, and the therapist, Melodie Nicholas, documented Mr. Cross' report of an area in the back of his neck primarily on the right side that is a little bit painful for him with associated mild headache beginning in the suboccipital region in the back of his head. She also documented his request to do a little bit of low back work. Physical medicine specialty evaluation was initiated on October 10, 2017 by Shimon Blau, M.D. He reviewed history of the motor vehicle collision and that Mr. Cross denied hitting his head or having a loss of consciousness with onset of few days later of left-sided lower neck and upper back pain radiating into his shoulder blades. Dr. Blau documented Mr. Cross' report that physical therapy over seven to eight sessions did not help and that massage therapy had just been started. He documented Mr. Cross' report that chiropractic care over a course of seven to eight weeks "has helped temporarily." Dr. Blau also documented aspects of Mr. Cross' past medical history (see Past Medical History). On examination, Dr. Blau documented tenderness to palpation along the bilateral medial and inferior scapular borders and upper thoracic region. He diagnosed Mr. Cross with cervicalgia and thoracic pain and recommended further diagnostic evaluation to include cervical and thoracic spine MRIs. These studies were both done on November 4, 2017 and interpreted by Kelly Lindauer, M.D. In the thoracic spine, Dr. Lindauer described scoliosis with a broad- based 5 mm left paracentral to posterolateral disc protrusion at T5-T6. A disc protrusion was also described at T6-T7 seen to mildly indent the thecal sac. A left paracentral to posterolateral disc extrusion was seen with mild cranial and caudal migration at T7-T8, measuring 4 x 4 x 11 mm seen to indent the left anterolateral thecal sac and contacted the anterolateral aspects of the thoracic spinal cord. Associated spondylosis and facet joint osteoarthritis was described along with a central disc protrusion at T8-T9 that was seen to indent the thecal sac and mildly indent the anterior aspect of the thoracic spinal cord. In the cervical spine, Dr. Lindauer described a left paracentral to posterolateral disc extrusion at C5-C6 measuring 4 x 10 x 10 mm seen to indent the left anterolateral thecal sac contributing to mild-to-moderate central spinal canal stenosis and severe left neural foraminal stenosis. Spondylosis and facet joint osteoarthritis were seen to involve multiple levels with associated mild-to-moderate central spinal canal stenosis at C5-C6 and C6-C7. Neural foraminal stenosis were seen to involve the left C4-C5 and right C4-C5, as well as bilaterally at C5-C6 and C6-C7. Neurology specialty evaluation of headaches was initiated by Arnaldo Da Silva, M.D. on December 12, 2017. Dr. Da Silva reviewed history and recommended medication trials of Lyrica with continuation of cyclobenzaprine. He also recommended electrodiagnostic evaluation of Mr. Cross' upper extremities. 1 Exhbit A - Page 2 INDEPENDENT MEDICAL EXAMINATION Stuward Cross July 26, 2021 Page 3 Dr. Blau then re-evaluated Mr. Cross on February 19, 2018. He noted that physical and massage therapy and especially chiropractic treatment had helped. He expressed that overall, Mr. Cross was doing significantly better, but with persistence of tightness from the left neck down his left arm. This extended along the medial elbow and into his left little digit, as well as inferiorly. He described constant burning neck pain and upper back pain rated at a scale of 4/10. Dr. Blau reviewed the MRI scan findings and concluded that Mr. Cross was approaching maximum medical improvement (MMI). He recommended maintenance care to include 8 to 12 chiropractic sessions and consideration of possible injections if he would develop more severe pain symptoms. The next medical record currently available to me was a note authored by Dr. Da Silva on January 9, 2018. He noted that electrodiagnostic evaluation had not been done in Mr. Cross' case and described his ongoing symptoms of cervical spine pain and headaches. Mr. Cross was assessed by his personal medical provider, physician assistant John Clifford Mann on February 20, 2019. Mr. Mann reviewed Mr. Cross' history of worsening pain over the preceding six months with shooting "explosive" pains that last 15 to 30 seconds that include low back and sciatic pain, as well as thoracic and sternal pain. Mr. Mann also documented Mr. Cross' trouble with episodic memory remembering dates and errands in the setting of bad headaches. With these emerging symptoms, he recommended MRI scan evaluations of the brain and cervical spine. These were both done on June 8, 2019 and interpreted by Isaac Jones, M.D. Dr. Jones described the brain MRI showed no acute intracranial abnormality. In the cervical spine, motion on the axial images limits evaluation and it does not appear that a comparison view was done with the previous MRI of 2017. EMG and nerve conduction studies were done by this time as outlined in medical records authored by physician assistant Bradley Martin. There was electrodiagnostic evidence of bilateral median neuropathy at the wrist, carpal tunnel syndrome seen to be very mild in severity bilaterally. There were no findings consistent with ulnar neuropathy bilaterally or of acute or chronic left cervical radiculopathy, brachial plexopathy, or myopathy as documented by Mr. Martin in his report of September 13, 2019. Mr. Cross was assessed by Arden Mahaffey, D.O. on September 10, 2019. Dr. Mahaffey documented symptoms of chronic neck pain as well as left shoulder pain. He recommended physical therapy for the left shoulder and consideration of a subacromial corticosteroid injection. 1 Exhbit A - Page 3 INDEPENDENT MEDICAL EXAMINATION Stuward Cross July 26, 2021 Page 4 Bradley Martin then reassessed Mr. Cross on December 6, 2019. This was a follow up visit for neck pain and he documented ongoing neck pain with weakness and numbness in his arm and particularly trouble with his left shoulder. Physical therapy was reinitiated on June 5, 2020 by Jordan Allison. Mr. Allison documented that Mr. Cross presented with chronic cervicothoracic as well as right shoulder pain. He documented in his follow up report of June 9, 2020 that Mr. Cross had "a lot of comorbidities" with increased depression since onset of COVID -19. Mr. Mann then reassessed Mr. Cross on July 13, 2020. He documented that dry needling and therapeutic exercises had helped, but that Mr. Cross reported being only "partially functional." He documented additional past medical history not contained in his earlier reports (see Past Medical History). By July 17, 2020, Mr. Cross' physical therapy report documented that he felt therapy "has been very helpful up to this point." Therapy was being discontinued due to scheduling issues. The most recent record I have is from Mr. Mann, who assessed Mr. Cross on March 10, 2021. This was a telehealth visit discussing referral to a spine specialist. Diagnosis at this time had changed to "spinal stenosis" and recommendation was made by Mr. Mann to refer Mr. Cross to a neurosurgeon. PAST MEDICAL HISTORY: I do have both records from prior to June 7, 2017, a s well as reference to other past medical history in medical records authored subsequent to this date. Records currently available to me begin with a reference that physician assistant John Mann referred Mr. Cross for a right shoulder x-ray to investigate right shoulder pain upon external rotation. This history was listed in a radiology report authored by Monique Fox, M.D. on December 21, 2015. Ms. Fox noted that the x -ray was negative for evidence of bony pathology. Mr. Mann then referred Mr. Cross for physical therapy with Amy La Tendresse, who initially assessed him on January 4, 2016. She documented his report of pain from his right neck down to his hand with a sense that he had limited motion in his neck, upper back, and right shoulder. An MRI of the right shoulder was done without contrast on January 5, 2016. The MRI was interpreted by Andrew Mills, M.D. as showing mild undersurface fraying involving the distal posterior infraspinatus fibers as well as mild tendinopathy involving the distal supraspinatus and infraspinatus. 1 Exhbit A - Page 4 INDEPENDENT MEDICAL EXAMINATION Stuward Cross July 26, 2021 Page 5 Past medical history is also documented in the report authored by Dr. Blau on October 10, 2017. He documented history of Mr. Cross working as a security guard and sustaining a gunshot wound to his right knee, requiring surgery several years previously. He documented Mr. Cross' report of being in a wheelchair for two years following this and that he stated he had chronic pain in his lower back and lower extremities on account of this particular work-related injury. Dr. Blau documented that Mr. Cross had been given an impairment rating of 18% lower extremity and 4% of the whole person. Past medical history was also documented by John Mann in his report of July 13, 2020. He documented Mr. Cross' recollection that he had collapsed discs in his neck, narrowing of the canal, and that he "was told many years ago, he would need surgery, but he is trying to avoid that as long as possible." ASSESSMENT: 1. Past medical history of cervical spine and right shoulder pain with documentation in notes dated July 13, 2020 that he "was told many years ago, he would need surgery" to address his cervical spine, presumably to address spinal stenosis. 2. Past medical history of a work-related gunshot trauma to Mr. Cross' right knee with subsequent chronic pain involving his lower back and legs as documented in notes dated October 10, 2017. 3. Motor vehicle collision with cervicothoracic spine sprain/strain injuries sustained June 7, 2017 with documentation of ongoing non-radicular cervicothoracic spine pain well beyond a period of six months. In his report of July 5, 2021, Dr. Thurston expressed opinions as outlined beginning on page 15. I will review and comment on his opinions in the order that they were presented by Dr. Thurston in his report: • Dr. Thurston concludes that Mr. Cross did not sustain a concussion or traumatic brain injury. I agree with this opinion. • Mr. Cross was documented by Dr. Thurston as having difficulty expressing himself and becoming frustrated and he concluded that this was more likely related to depression and stress. I agree with this op inion as well. • Dr. Thurston noted that the thoracic spine MRI did not demonstrate acute injuries attributable to the June 7, 2017 motor vehicle collision. I agree with his opinion that narrowing of the bony cervical canal is a congenital rather than a traumatic finding. However, I disagree with Dr. Thurston that thoracic disc protrusions and extrusions are unrelated to the motor vehicle collision. I recommend further spine specialty assessment of this particular question. 1 Exhbit A - Page 5 INDEPENDENT MEDICAL EXAMINATION Stuward Cross July 26, 2021 Page 6 • In the next two opinions, Dr. Thurston expressed that Mr. Cross' cervical and thoracic disc bulges and protrusions were not accelerated, exacerbated, or aggravated by the motor vehicle collision of June 7, 2017. I recommend that this question be addressed by a spine specialist, who has access to all of the spinal MRIs that have been done over time. The same opinion is true regarding multiple cervical neural foraminal stenosis and facet osteoarthritis. • Dr. Thurston concluded that the motor vehicle collision in questi on was a low energy event. I agree with this opinion, but conclude that forces were sufficient for Mr. Cross to have sustained a soft tissue cervicothoracic spine sprain/strain superimposed on his underlying degenerative disc disease and spinal stenosis. • Dr. Thurston concluded that Mr. Cross did not experience any physical injury to his neck, shoulder, arms, head, or brain as a result of the motor vehicle collision of June 7, 2017. I disagree with this opinion and conclude that Mr. Cross did sustain a soft tissue cervicothoracic spine sprain/strain as a result of the motor vehicle collision. • Dr. Thurston concluded that carpal tunnel syndrome as diagnosed by electrodiagnostic testing was not caused by or accelerated by the motor vehicle collision of June 7, 2017. I agree with this opinion. • Dr. Thurston noted that "even if Mr. Cross had experienced a mild cervical and/or thoracic myofascial strain, these physical injuries would have spontaneously resolved in two to three weeks at most without residuals." I disagree with this opinion and believe that Mr. Cross has sustained a cervicothoracic spine sprain/strain with persistence of non-radicular pain. In conclusion, I disagree with Dr. Thurston regarding injuries that Mr. Cross sustained on June 7, 2017. I believe Mr. Cross sustained a cervicothoracic spine sprain/strain as a result of the motor vehicle collision. Medical evaluation and treatment from the time of his initial evaluation at Concentra and continuing through the time of Dr. Blau’s report of February 19, 2018, was reasonable, necessary and related to the motor vehicle collision of June 7, 2017. Mr. Cross probably has reached maximum therapeutic benefit with respect to injuries he sustained June 7, 2017. However, given the complexity of his past medical history, I believe he needs to have a reevaluation by Dr. Blau as well as by a spine surgeon in an effort to sort out what further evaluation and treatment he might require as a result of this motor vehicle collision. I was asked if I felt he was predisposed to cervicothoracic spine injuries as a result of pre-existing spinal pathology. He probably was predisposed, but my current 1 Exhbit A - Page 6 INDEPENDENT MEDICAL EXAMINATION Stuward Cross July 26, 2021 Page 7 impression is that he sustained superimposed soft-tissue injuries. It is my opinion that he has both preexisting and MVC-related permanent impairment that may be rated according to the AMA Guides to the Evaluation of Permanent Impairment, Sixth Edition. As a result of the motor vehicle collision, I believe Mr. Cross has a diagnosis of cervical spine “whiplash” or strain/sprain injury as defined by the AMA Guides on Table 17-2. This has a median permanent impairment of 2% whole person with a range from 1 to 3%. Given the limitations inherent to case review as opposed to direct medical evaluation of an individual, I will not attempt to do any a djustment of this impairment, leaving it at the median value of 2% whole person. Sincerely, John S. Hughes, M.D. 1 Exhbit A - Page 7