8 th Annual W/C Spine Summit. Ted A. Lennard, MD Feb. 12, 2015

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1 8 th Annual W/C Spine Summit Ted A. Lennard, MD Feb. 12, 2015

2 Case Study 45 y.o. male Truck Accident on 1/15/12 Slid on ice and crossed median.

3

4 Case Study Taken by ambulance to ER in Texas +Loss of consciousness +Neck pain

5 Case Study CT of head Negative Cervical x-rays - Loss of cervical lordosis +Neck pain

6

7 Past Cervical spine history s/p C5-6 ACDF (2/5/04) from work accident Surgeon discussed extending fusion in the future Post op returned to full activities and work 20% disability to the body as a whole Intermittent residual neck pain.

8 Past Concussion History MVA, 2006, residual occasional headaches, rare dizziness. MVA, 2010, struck head on glass. + LOC. Mild cognitive impairment on Neuropsych evaluation.

9 Past Medical History Diabetes Depression

10 Social History Divorced 5 children High School Education Smokes 1 ppd since 1995 ETOH moderate

11 Work History 25 year truck driver Multiple employers; Current employer x 6 months Minimal lifting required

12 Non-Operative Tx 1/20/12 Evaluated by Occupational Medicine physician Symptoms Neck and right scapular pain; dizziness, headaches, blurred vision;

13 Non-Operative Tx Exam Obese; Neck spasms; Limited ROM; Balance problems Treatment included medications, altered activity and physical therapy.

14 Non-Operative Tx No improvement with 2 weeks of PT Balance remains poor Dizziness is worse Neck pain is worse Headaches are intolerable MRI of the head is recommended.

15

16 Non-Operative Tx FU with Occupational Medicine No symptom improvement Dx: Cervical strain and concussion Physiatry referral

17 Non-Operative Treatment 3/1/12 Evaluated by physiatrist Symptoms Headaches, Dizziness, Visual changes, Cognitive difficulties, Neck pain, Right scapular and upper extremity tingling and pain.

18 Non-Operative Treatment Exam; Obese; Neck tenderness; Limited ROM; Altered sensation in the right middle digit; poor balance MRI of the cervical spine Neurology consultation

19 MRI of the Cervical Spine C5-6 ACDF Degenerative changes at C4-5 and C5-7 with mild stenosis. Widespread spondylosis Facet joint degenerative changes

20 Cervical Spine Treatment Physical therapy Changes in medications Cervical traction Two cervical epidural steroid injections at the C6-7 level

21 Cervical Spine Treatment Abnormal EMG study of the RUE Altered sensation in the 3 rd digit of the right hand Right triceps weakness Neurosurgical consultation

22 Concussion Treatment Neurology evaluation Changes in medications Physical therapy

23 Surgical Evaluation Surgical evaluation (5/1/12) CT Myelogram (5/5/12) findings: Right C7 nerve root compression; C6-7 ACDF recommended

24 Prior to Surgical Approval Old Medical Records PCP: 10/1/11.. Neck pain and headaches PCP: 12/4/11. upset with employer, thinking about quitting his job. PCP: 1/10/12 c/o dizziness, neck pain, and headaches (DOI 1/15/12)

25 Prior to Surgical Approval Neurosurgeon.. 9/5/04 (ACDF 2/5/04).. patient experiencing tingling in the right 3 rd digit. NS: 7/7/06.. Intermittent right upper extremity pain, tingling in the right 3 rd digit.

26 Surgery C6-7 ACDF (5/15/12) No complications

27 Post - Operative RUE pain resolved Neck pain remained present Overall improved Completed PT for neck.

28 Post Operative Exam Moderate limits in cervical ROM Mild tenderness in the neck region. Improving right triceps strength Altered sensation in the right 3 rd digit (improved) Normal reflexes

29 Concussion Treatment Multiple follow ups with Neurologist Side effects with most medications Headaches, dizziness, balance problems persist

30 Concussion Treatment Neuropsychological evaluation Symptom magnification Depression

31 Post - Operative FCE: Invalid test; lb lifting limit recommendation; Driving test Avoid commercial driving MMI date: 10/1/12

32 Current Situation Moderate neck pain, headaches, dizziness, balance problems. RUE intermittent pain, 3 rd digit numbness Pain is worse with prolonged activities Medications reduce his headaches

33 Current Situation Continues to smoke 1 ppd Weight 280 lbs (Gained 10 lbs last 3 months) Neck exercises aggravate his pain Depression controlled on meds Unable to return to previous work due to restrictions

34 The Truck Accident on 1/15/12 WAS the prevailing factor in the development of his right C7 radiculopathy (pinched nerve.) Was NOT the prevailing factor in the right C7 radiculopathy (pinched nerve.) I have no clue!. I need help on this one!

35 The Truck Accident on 1/15/12 WAS the prevailing factor in the development of his concussion. Was NOT the prevailing factor in the concussion. There is nothing wrong with this guy!

36 What helps the most with deciding the prevailing factor? Details of the truck accident and early medical records Old Medical records Neuropsychological findings FCE findings Your legal counsel opinion

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