Decision #09/04 - Type: Workers Compensation

Preamble

An Appeal Panel hearing was held on September 29, 2003, at the request of a union representative, acting on behalf of the claimant. The Panel discussed the appeal on September 29, 2003 and again on December 2, 2003.

Issue

Whether or not responsibility for any proposed carpal tunnel surgery should be accepted at this time.

Decision

That responsibility for any proposed carpal tunnel surgery for the right wrist only, should be accepted at this time.

Decision: Unanimous

Background

In February 2002, the Workers Compensation Board (WCB) received the claimant's application for compensation benefits whereby the claimant reported that both of his hands gradually became symptomatic due to the repetitive nature of his job duties which included bucking, drilling, squeezing clamps, etc.

On March 26, 2002, a WCB adjudicator spoke with the claimant by telephone to gather further particulars regarding his job history with the employer and the onset of his symptoms. Medical information was also received from the attending physician who diagnosed the claimant with an overuse strain of the right hand extensor tendons. Medication and physiotherapy treatments were prescribed. On March 27, 2003, the claim was accepted based on the physician's diagnosis and four hours of wage loss benefits were paid to the claimant. In the interim, the claimant returned to work performing modified duties.

In a progress report dated May 16, 2002, the attending physician suspected that the claimant had right carpal tunnel syndrome in addition to the overuse wrist extensor strain. Nerve conduction studies (NCS) were ordered and were carried out on June 18, 2002.

A WCB medical advisor reviewed the NCS results and the file information at the request of primary adjudication on August 29, 2002. The medical advisor opined that based on the NCS report, there was no indication for surgical intervention and that the diagnosis may be in doubt.

The claimant was assessed by a WCB physical medicine and rehabilitation specialist (physiatrist) on October 10, 2002.

After reviewing the physiatrist's examination findings, a WCB adjudicator wrote to the claimant on November 5, 2002. The claimant was advised that it was the physiatrist's opinion that he had hypothyroidism, a pre-existing condition, which was probably the cause of his mild peripheral neuropathy. The physiatrist felt there was no evidence of tenosynovitis or tendon irritability and that the claimant's workplace injury had now resolved. In view of this determination, the claimant was informed that the WCB would not accept any further responsibility for medical treatment, time loss from work, or prescription medication.

On December 10, 2002, a union representative provided a submission to the Review Office which included a report from the claimant's physician dated November 18, 2002 along with literature pertaining to Carpal Tunnel Syndrome. Based on this information, the union representative contended that the claimant had not recovered from his compensable injury and was entitled to further benefits and services.

In a January 10, 2003 decision, Review Office determined that the claimant was not entitled to further wage loss benefits and services. Review Office pointed out that the claim had been accepted as a right hand extensor tendon strain and that the CTS literature provided by the union was not relevant to the issue under review. Based on the examination results of the WCB physiatrist, Review Office believed that the claimant had recovered from the effects of his work related strain and that his pre-existing thyroid condition may be the cause for his mild peripheral neuropathy. Review Office noted as well that it was the WCB physiatrist's opinion that the claimant's minor irritability of the first carpometacarpal joints bilaterally, can be accounted for by early osteoarthritic involvement.

In March 2003, the union submitted to Review Office additional information from an orthopaedic specialist, the family physician and a blood chemistry report for consideration.

The family physician referred to a NCS report dated January 28, 2003 and stated that there was little doubt that the claimant suffered from bilateral carpal tunnel syndrome. The orthopaedic specialist commented that hypothyroidism was one of the risk factors for CTS and that the claimant had another risk factor for CTS which was the operation of vibrating tools and repetitive use of his hands. He felt that the claimant's CTS condition, on a balance of probabilities, was likely caused by his job duties. He also made reference to a statement made by the family physician that the claimant's symptoms resolved completely while he was on vacation for three weeks during the summer with a rapid recurrence of the symptoms when returning to work. The specialist's treatment plan was to include carpal tunnel release on both hands, the right one first, with the claimant's giving his consent to do so.

Prior to considering the union's appeal, Review Office obtained medical advice from the WCB's physiatrist on March 21, 2003.

On May 9, 2003, Review Office determined that the claimant had not recovered from the compensable injury, that his work duties are considered to have aggravated a pre-existing CTS condition and that no responsibility would be accepted for any proposed surgery on the carpal tunnel at this time. Review Office stated the following in its decision:
  • clinically, the attending physicians have reported that the claimant now has mild borderline CTS and that the NCS reports are still borderline for supporting this diagnosis.

  • Review Office agreed with the WCB's physiatrist's opinion that the claimant's work activities likely did aggravate an underlying carpal tunnel condition and that this was an ongoing situation. Responsibility was being accepted for the aggravation.

  • Review Office agreed with the WCB physiatrist's opinion not to authorize surgery in the form of carpal tunnel release at this time because of the borderline findings.
In June 2003, the claimant appealed Review Office's decision to deny responsibility for any proposed surgery to his carpal tunnel and an oral hearing was requested and arranged.

Following the hearing and discussion of the case, the Appeal Panel requested and received further medical information from the treating orthopaedic surgeon which was forwarded to the interested parties for comment. On December 2, 2003, the Panel met to render its final decision.

Reasons

The claimant underwent a right carpal tunnel release on March 28, 2003. This Panel is of the opinion that the surgery was necessary and well supported by medical opinion. Given that the WCB has accepted responsibility for the claimant's right carpal tunnel syndrome as being work related, we find that the surgery for the release should be a WCB responsibility as well.

Prior to the surgery being performed, two of the claimant's doctors supported the need for the claimant to have a right carpal tunnel release. The claimant's family physician, in a report dated November 18, 2002, placed some emphasis on the report of the claimant that "his wrist/hand symptoms resolved completely while he was on vacation for 3 weeks during the summer, with a rapid recurrence with returning to work." Her earlier opinion was an "overuse strain of the right hands" and x-rays that she had ordered dated January 31, 2002 showed that a "benign appearing subcortical cyst [was] visible in the head of the third proximal phalanx." She prescribed the claimant with CTS wrist braces and advised him to refrain from performing any tasks that require repetitive or vibratory usage of the hands and wrists.

The claimant's orthopaedic specialist found both a positive Phalen's test on the right and left hands and a positive Tinel's sign for carpal tunnel on the right and left hands. On a balance of probability, this specialist felt that there was carpal tunnel syndrome present and that it was likely work related. This specialist also was of the view that CTS requiring surgery is a clinical diagnosis and that nerve conduction studies (which were essentially normal in this case) were not always that useful and could be both wasteful and confusing. He felt that "a nerve conduction study is reserved for those cases where CTS is not clearly demonstrated by a physical exam." He also noted that "patients can have CTS and have a normal or near-normal nerve conduction study." He appeared to be of the opinion that this was just such a case where CTS was clinically demonstrated but not evident in the nerve conduction study.

The WCB specialist in physical and rehabilitation medicine saw the claimant on October 10, 2002. He was of the opinion that the claimant was suffering from a pre-existing CTS condition caused by pre-existing hypothyroidism and that work, along with the hypothyroidism, likely aggravated the claimant's condition. He was not prepared to authorize surgery at that point in time as the nerve conduction studies were borderline. He felt that further nerve conduction studies should be repeated within six months to see if the condition had progressed and that a decision on surgery would be made at that time.

The claimant went ahead with the surgery anyway on March 28, 2003 and testified that due to the increasing pain and his subsequent complete disability, he felt that he had no choice. He testified that, after the surgery, his strength in his right hand increased, his range of motion increased and the tingling decreased. The surgeon, in his report dated October 17, 2003 reported that "his numbness and tingling and night symptoms were currently gone" (as of June 4, 2003). The surgeon found that the surgery was only partially successful in relieving the claimant's symptoms in his right hand as there had, subjectively, only been a 50% improvement in his symptoms. However, in this surgeon's opinion there was success as this was a 50% decrease in the intensity of the claimant's symptoms pre-operation.

This Panel is of the opinion that if the results of the surgery would have been known, it is likely that prior approval would have been given by the WCB. This opinion is in accordance with the WCB policy on "Elective Surgical Procedures" which states as follows:
"2. If elective surgery is undertaken without prior approval, the WCB may accept responsibility if prior approval would have been granted had it been requested."
The WCB specialist did not at any time rule out the need for surgery, he simply said to wait for six months and then review the situation. Accordingly, this Panel is of the unanimous view that the need for surgery was supported by a majority of doctors managing the claimant's healthcare, that the need for surgery was not overruled by the WCB specialist and that the surgery would have eventually been authorized by the WCB. Responsibility by the WCB should therefore be accepted with respect to the right carpal tunnel surgery. We make no comment with respect to the need for surgery on the left wrist as there is insufficient information on file detailing the left wrist condition.

Panel Members

K. Dunlop, Q.C., Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

K. Dunlop, Q.C. - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 21st day of January, 2004

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