Decision #111/03 - Type: Workers Compensation

Preamble

An Appeal Panel hearing was held on May 7, 2003, at the claimant's request. The Panel discussed this appeal on May 7, 2003 and again on September 5, 2003.

Issue

Whether or not the worker is entitled to payment of wage loss benefits beyond June 25, 2002.

Decision

That the claimant is not entitled to payment of wage loss benefits beyond June 25, 2002.

Decision: Unanimous

Background

On September 11, 2000, the claimant reported an injury to his left lower back as a result of lifting and moving chairs during the course of his employment as an assistant custodian. The diagnosis rendered by the attending physician was a right lumbar strain and possible right sciatica. The claimant missed eight days of work as a result of the accident and had returned to work on September 25, 2000 in spite of his back still being sore.

On November 27, 2000, the claimant again injured his low back while moving tables at work. Initial medical reports revealed that the claimant was diagnosed with a right lumbar strain and was prescribed medication and physiotherapy treatments. The Workers Compensation Board (WCB) accepted the claim and wage loss benefits were paid to the worker commencing November 28, 2000.

On February 26, 2001, the claimant had undergone a CT scan of the lumbosacral spine. The results revealed mild annular disc bulging without evidence of disc herniation, spinal stenosis or nerve root involvement at the L3-L4 and L4-L5 levels. At the L5-S1 level, there was facet hypertrophy. There was no evidence of disc herniation, spinal stenosis or nerve root involvement. Mild annular disc bulging was present. Visualized portions of the SI joints were normal.

A WCB medical advisor assessed the claimant on April 18, 2001. Based on history and physical examination, the medical advisor commented that the claimant demonstrated findings of mechanical low back pain. The medical advisor suggested that the claimant should undergo additional testing and a referral was made to a physical medicine and rehabilitation specialist (physiatrist).

In a report dated July 6, 2001, the physiatrist indicated that the claimant did not demonstrate any findings of nerve root impairment or active nerve root irritation. He agreed that the sacroiliac joint could be responsible for some of the claimant's symptoms. There appeared to be dysfunction of the right hip. The specialist arranged for the claimant to undergo pelvis and right hip x-rays. Furthermore, the specialist indicated that if there were no significant findings at the hip, then he would proceed with a diagnostic/therapeutic injection to the right SI joint.

On July 5, 2001, x-rays of the pelvis were reported as showing symmetric hip joints with no appreciable narrowing. There was questionable effusion of the right hip joint which was not well seen on this view. Further assessment of the SI joints with Hibb's view was suggested.

On July 13, 2001, x-rays of the sacroiliac joints appeared unremarkable and no significant abnormalities were seen.

On October 17, 2001, the physiatrist performed a right sacroiliac joint injection.

Progress reports from the attending physician noted that the claimant's status had not improved after receiving the injection to his right lower back and that the claimant remained tender in the right paralumbar musculature. A referral to an acupuncturist was suggested.

On January 10, 2002, the physiatrist reported that the claimant had his second right sacroiliac joint injection on December 13, 2001 and that the injection had no lasting effect on the claimant. The physiatrist felt that therapeutic options were limited.

In a progress report of March 7, 2002, the attending physician noted that the claimant remained tender over the right SI joint and that forward flexion was approximately 60 degrees.

On April 5, 2002, x-rays of the lumbosacral spine revealed moderately severe degenerative narrowing of the L3-L4 disc space. There was also osteoarthritic narrowing of the L2-3 joints on the right. No other abnormality was identified.

On May 17, 2002, a WCB orthopaedic consultant reviewed the case at the request of primary adjudication. The current diagnosis with respect to the claimant's condition was degenerative disc disease at L3-4 and osteoarthritis at the L2-L3 facet joints. The consultant indicated that these conditions were pre-existing and that they were likely aggravated by the claimant's work activities and that the aggravation should now be resolved. There was no objective evidence of any enhancement and the consultant did not think that the claimant's pain was due to problems in his SI joint.

Based on the opinion expressed by the WCB orthopaedic consultant and the weight of evidence, primary adjudication determined on June 18, 2002, that the claimant had recovered from the effects of his workplace injury and that wage loss benefits would be paid to June 25, 2002 inclusive and final. On June 19, 2002, the claimant appealed this decision to Review Office.

Prior to considering the claimant's appeal, Review Office sought the medical advice of an orthopaedic consultant on August 27, 2002.

In a decision dated August 30, 2002, Review Office noted that the original diagnosis of the worker's condition was a low back sprain or strain and this had been confirmed by the orthopaedic consultant to Review Office. There was no evidence to support the claimant's contention that this accident caused the findings reported on x-ray and there was no evidence to suggest that these findings were permanently made worse or enhanced by this accident. Review Office noted that two WCB orthopaedic specialists have now indicated that the ongoing condition was degenerative disc disease and osteoarthritis and that the aggravation caused by this accident was now over. Under these circumstances, the claimant was no longer entitled to payment of wage loss benefits. On November 1, 2002, the claimant appealed Review Office's decision and an oral hearing was requested.

On January 27, 2003, a worker advisor asked Review Office to reconsider its decision based on submitted medical reports from the claimant's treating physiatrist and attending physician who supported reinstatement of wage loss benefits. On February 19, 2003, Review Office again sought the medical advice of a WCB orthopaedic consultant prior to responding to the worker advisor's appeal submission.

In a decision dated February 21, 2003, Review Office confirmed that the claimant was not entitled to payment of wage loss benefits beyond June 25, 2002. Review Office noted that it was the opinion of the worker advisor and the claimant that the claimant had a sacroiliac joint injury that was caused by the accident. Review Office stated that in order to sustain any type of significant injury to this particular joint, that major trauma was normally involved. That did not occur in this case.

Furthermore, Review Office felt that the weight of evidence did not support the attending physician's opinion that the worker's right SI joint dysfunction was related to the mechanics of the accident. The physiatrist advised the claimant to have further diagnostic injections prior to consideration of more radical treatment such as a fusion of the joint, to confirm that the pain was in fact arising from the joint. This meant to Review Office that the physiatrist was not entirely positive that the SI joint was to blame for the claimant's claim of ongoing back difficulties. Given the nature of the work related accident and the diagnosis of a right lumbar strain, Review Office believed that the claimant had recovered form the effects of his accident by June 21, 2002. On March 18, 2003, the claimant appealed Review Office's decision and an oral hearing was arranged.

Following the hearing and discussion of the case, the Appeal Panel decided to arrange for the claimant to be examined by an independent orthopaedic consultant to:
  1. Identify a specific diagnosis in relation to the claimant's lower back condition; and

  2. To determine whether or not his lower back condition was related to either of his two compensable accidents and/or to a pre-existing condition.
On July 10, 2003, the claimant was assessed by an orthopaedic consultant and his report dated July 11, 2003 was forwarded to the interested parties for comment. On September 5, 2003, the Panel met to render its final decision with respect to the issue under appeal.

Reasons

This case involves a worker who injured his lower back, in November 2000, in the course of his employment as a school custodian. His claim for compensation was accepted and benefits were paid accordingly.

By June 2002, it had been determined that any ongoing problems were not related to his workplace injury and benefits were terminated. This decision was upheld by Review Office in an August 2002 decision. Review Office found that his problems were due to pre-existing degenerative disc disease and osteoarthritis. The aggravation caused by the accident had resolved.

He requested another reconsideration based on a report from his general practitioner who believed the claimant to be suffering from sacroiliac joint dysfunction. Again, Review Office upheld the earlier decision to terminate benefits. He then appealed to the Appeal Commission.

The issue before the Appeal Panel was whether or not the claimant was entitled to wage loss benefits beyond June 25, 2002.

For his appeal to be successful, we would have to determine that the cause of his ongoing problems with his lower back is his workplace injury of November 2000. We were not able to come to that determination.

In coming to our decision, we conducted a thorough review of the claim file, as well as holding a hearing, at which we heard testimony from the claimant. Subsequent to the hearing, we referred the claimant to an orthopaedic surgeon for an independent medical examination.

In our deliberations, we took particular note of the following:
  • Following his accident, the claimant was initially diagnosed as having a right lumbar strain. Subsequent progress reports noted that he was improving.

  • As noted above in the Background section, a CT exam conducted in February 2001 found mild disc bulging in his lumbar region, from L3 to S1, with no disc herniation, spinal stenosis or nerve root involvement. Some facet hypertrophy was found at L5 - S1. This CT scan noted that the part of his SI joints that was seen was normal.

  • The first mention of any pain in his SI joints is in a progress report from his doctor on March 16, 2001.

  • Upon examination, a specialist in physical medicine agreed that there might be some involvement of his right sacroiliac joint. He referred the claimant for an x-ray which reported: "The sacroiliac joints appear unremarkable and no significant abnormalities are seen."

  • Injections into the sacroiliac area provided only temporary relief.

  • After reviewing the file, a board medical advisor wrote that he doubted "that symptoms are due to the SI joints - x-rays and bone scans were negative here." He recommended further x-rays to check for degenerative disc disease.

  • This x-ray, done in April 2002, reported:

    • "There is moderately severe degenerative narrowing of the L3-4 disc space. There is also osteoarthritic narrowing of the L2-3 facet joints on the right. No other abnormality is identified."
  • In December 2002, his family doctor diagnosed him as having "right SI joint dysfunction as a result of his injury." In response to this, a board specialist in orthopaedics wrote that "injury of any significance to the SI joint requires major trauma, which he did not experience." It was also his opinion that the claimant had recovered from the effects of the accident by June 25, 2002.
It was to help us interpret these somewhat differing opinions and diagnoses that we referred the claimant for an independent medical examination.

The orthopaedic specialist wrote:
  • "…. the most probable diagnosis of [the claimant's] current low back condition is degenerative changes of the lumbar spine."

  • "The degenerative changes the patient has of his lumbar spine are not caused by either the September nor the November 2000 workplace injuries."

  • "This patient did have pre-existing degenerative changes of the lumbar spine."

  • "It is my opinion that the workplace injury the patient had did aggravate the pre-existing condition … there was a temporary aggravation … the September 2000 injury caused a temporary aggravation … the patient had not fully recovered from that temporary aggravation when he aggravated it further with the injury of November 2000 … the patient should have recovered from that temporary aggravation within nine months to a year."

  • "It is my opinion that the patient has now recovered from the effects of the workplace injuries of September and November 2000."
In respect of the claimant's pain in his right SI joint, this specialist wrote that he could draw no conclusions from the attempted injections. He did note that an x-ray of the SI joints was normal and that a bone scan showed no increased uptake in the sacroiliac.

Our analysis of the medical history noted above, as well as the report of the independent medical examiner has led us to conclude that - on a balance of probabilities - the claimant had recovered from the effects of his workplace injuries by June 25, 2002. thus no wage loss benefits are payable beyond that date.

Accordingly, the appeal is dismissed.

Panel Members

T. Sargeant, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

T. Sargeant - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 8th day of October, 2003

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