Opinion ID: 2597
Heading Depth: 3
Heading Rank: 1

Heading: The Evidence from Dr. Smith and the MRIs

Text: Burgess, on her initial visit to Dr. Smith three days after her accident, complained of swelling and buckling of her left knee, which upon examination revealed diffuse swelling and tenderness and a limited range of motion. (Report of Dr. Milton Smith dated October 10, 1997.) X-rays on Burgess's knees were negative, and Dr. Smith diagnosed [i]nternal derangement of the left knee. ( Id. ) At that time, Dr. Smith noted that Burgess had started a course of physical therapy, and he opined that she could work in a sedentary position. In December 1997, Burgess complained of left knee pain and continued back pain. (Report of Dr. Milton Smith dated December 12, 1997.) She had limited ranges of motion in her back and knee, was then working in a sedentary position, and was receiving physical therapy. ( See id. ) Dr. Smith's reports for January and February 1998 stated that Burgess continued to report pain and buckling in her left knee, and on March 17, 1998, an MRI was taken of that knee. That MRI showed that there was a SMALL AMOUNT OF FLUID IN KNEE JOINT WITH GREATER AMOUNT OF FLUID IN LATERAL ASPECT OF SUPRAPATELLAR RECESS. SUGGEST POSSIBLE TRUNCATION, NOTCH ASPECT OF POSTERIOR HORN OF MEDIAL MENISCUS. (Report of Dr. Franklin Turetz dated March 19, 1998.) Dr. Smith examined Burgess on March 20 and reported that she continued to have pain in her left knee. His report noted that the MRI showed evidence of a torn medial meniscus and that the Workers' Compensation Board had authorized arthroscopic surgery. Dr. Smith performed the arthroscopic surgery on Burgess's left knee in May 1998. His operative report stated that no tear of the meniscus was found, but that there was hypotrophic synovium throughout the knee. At the Workers' Compensation Board hearing (two years later) Dr. Smith explained that hypotrophic synovium was an inflammatory process that was not reparable through surgery and that Burgess likely would eventually need knee replacement. (Workers' Compensation Board Hearing Transcript May 8, 2000 (WCB Tr.), at 17.) He stated that although the arthroscopy showed no large tears, the meniscus was fragmented and that a lot of small pieces ... had to be irrigated out. ( Id. at 16.) On May 29, 1998, some three weeks after the knee surgery, Dr. Smith's examination report stated that Burgess still had pain in her knee and in her lower back, but with improving range of motion. In June, Dr. Smith reported that Burgess was experiencing less pain in her knee, and had an improved, albeit still limited, range of motion; he opined that she could perform sedentary work. In July, he reported that Burgess had continued pain in the knee, with an improved but still limited range of motion. From August through December 1998, Dr. Smith's monthly reports on his examinations of Burgess stated that she continued to have pain in her left knee, as well as pain in her neck and back, all with limited ranges of motion. On January 8, 1999, an MRI was performed on Burgess's back. The report on that MRI stated, inter alia, as follows: Evaluation of the far sagittal images through the neural foramen reveal encroachment of the left neural foramen of L2-3 by what appears to be disc material, producing stenosis in the anterior/posterior direction. (Report of Dr. Javier Beltran (MRI Report) dated January 8, 1999, at 1 (emphasis added).) Dr. Smith examined Burgess on January 20, 1999, and his report noted that the MRI on Burgess's spine revealed a protruding disc at the L2-3 level. (His testimony elaborating on this at the Board hearing is discussed below.) Her treatment regimen continued to consist of over-the-counter pain relievers, warm soaks, and active range of motion; Dr. Smith noted that the Workers' Compensation Board had discontinued authorization for Burgess's physical therapy and he requested its reinstatement. From March 1999 through October 1999, Dr. Smith's reports of his monthly examinations of Burgess stated that she continued to have pain in her back and one or both of her knees, and limited ranges of motion. Dr. Smith's view of Burgess's capabilities in August 1999, according to the boxes he checked on a physical-capacities-evaluation form, was that Burgess could sit, stand, or walk for no more than three hours out of an eight-hour workday, and that she could not lift or carry more than five pounds. Dr. Smith's report in December 2000 stated that Burgess continued to have pain in her leg, neck, and back, with limited ranges of motion. It stated that Burgess is not able to return to work. She has a total degree of disability. (Report of Dr. Milton Smith To Whom it May Concern dated December 7, 2000.) Dr. Smith's reports in 2001, following examinations of Burgess virtually every month, similarly described Burgess as continuing to experience pain in, inter alia, her neck, back, and left knee. In late 2001 the reports indicate that Dr. Smith diagnosed Burgess with, inter alia, in addition to the continued derangement of her left knee, a cervical sprain and lumbosacral radiculopathy. In his testimony before the Workers' Compensation Board in May 2000, Dr. Smith stated that his initial diagnosis of Burgess's injuries was internal derangement of the left knee, which was caused by the accident. At that point, Burgess had a marked disability and could work only in a sedentary position. (WCB Tr. 4.) Dr. Smith explained that he amended his initial findings to add findings of neck and back injuries because they resulted from Burgess's initial injury, and that the fact that he did not mention them in his initial report did not mean that Burgess had not experienced pain in those areas. Dr. Smith testified that Burgess had an MRI of the lumbar spine dated 1/8/99 which showed presence with protrusion of the dis[c] at the L2-3 level which was protruding into the neural foramen, which mean[t] that she has a nerve root that [wa]s being pushed upon by the dis[c], which [wa]s very painful. ( Id. at 5.) He testified that his clinical findings on examination [were] consistent with the MRI. ( Id. ) Questioned further, Dr. Smith testified the MRI Report's revelation that there was protrusion into the neural foramen at L2-3 mean[t] that the dis[c] has changed its normal shape and part of that dis[c] is now pushing out into the foramen, which is the hole through which the nerve root exits the spine. In so doing, it's encroaching on the space that is normally there in the nerve root. So every time the patient moves a certain way it drags that nerve root across the dis[c] material and is very painful. (WCB Tr. 8-9 (emphases added).) Dr. Smith testified that although the MRI Report did not say directly that Burgess's disc was impinging on the nerve root, it so stated indirectly. Evaluation of the far sagittal images. That means the images over the site through the neural foramen reveal encroachment, which means, take up the space of the left neural foramen of L2-3 by what appears to be dis[c] material producing stenosis in the anterior, posterior direction. Stenosis is a narrowing and, thereby, pinches in the neural foramen. If there is stenosis, by definition, the nerve root is being severed. .... ... Normally the nerve root passes from the spinal cord out through this hole and goes to the lower extremities. If you have any object in that hole, whether it is arthritis or a tumor or dis[c] material, as in this case, it's taking up part of the space that is normally filled by the nerve. There is usually a little space within that hole around the nerve. The reason for this space is that as the person moves and bends that nerve is pulled tight around the edge of that hole. If you put a foreign object in this, in this case dis[c] material, there is no room for the nerve root to move. In certain positions, each time the person moves their body it creates superficial pain. ... What happens is that the nerve root normally passes through a small space. There is normally excess space so the body could move. If you occupy that space with something else, you are effectively pinching that nerve each time the person moves. ( Id. at 9-11 (emphases added).) Thus, although [t]he MRI d[id] not specifically say that the nerve root is impinged, it us[ed] other words that mean the exact same thing. ( Id. at 11-12.) Dr. Smith's April 18, 2002 report To Whom it May Concern described Burgess's condition as of that date and gave an overview of her condition for the 4 ½-year period in which he had treated her. As of April 2002, Burgess still complained of pain in her neck, back, and left knee, and had limited ranges of motion in those areas. Her course of treatment included the pain reliever Motrin and an active range of motion, with a follow-up visit scheduled for four weeks later. Dr. Smith concluded that Burgess has been totally disabled throughout the course of my treatment of her and remains severely restricted in her ability to function in a normal routine. In May 2002, Dr. Smith filled out a physical-capacities-evaluation form and checked boxes opining that Burgess could sit for a total of no more than one-to-two hours out of an eight-hour workday. In addition, he opined that she could stand and walk for a total of one hour out of an eight-hour workday, but could do each only for fifteen minutes at a time.