Decision #48/07 - Type: Workers Compensation
Preamble
This appeal deals with whether the worker’s L5-S1 back problems are related to his October 6, 1993 compensable injury.
The worker filed a claim with the Workers Compensation Board (WCB) for multiple injuries that he sustained on October 6, 1993 while performing his regular work duties as a lineman. The WCB and Review Office accepted that the worker’s L4 compression fracture was a result of his accident but denied responsibility for his L5-S1 back problems as being related to his compensable injury. The worker appealed to the Appeal Commission and a hearing was held on February 14, 2007. The panel discussed this appeal following the hearing.
Issue
Whether or not the worker’s L5-S1 back problems are related to the October 1993 compensable accident.Decision
That the worker’s L5-S1 back problems are related to the October 1993 compensable accident.Decision: Unanimous
Background
The worker filed a compensation claim with the WCB for injuries that occurred at work on October 6, 1993 when he slid off a pole and fell 30 feet to the ground, landing on both feet. The WCB accepted the claim based on the diagnoses of a compression fracture at the L4 area and compound bilateral ankle fractures.
With respect to the worker’s back condition, x-rays were taken of his lumbar spine on October 7, 1993. The radiological report stated, “The first sacral segment is lumbarized. Five lumbar type vertebrae. There is a slight compression fracture involving the anterior and right side of the fourth lumbar vertebral body. It is perhaps a 5 to 10% compression fracture. A fracture of the pelvis is evident.” Further x-rays of the lumbosacral spine taken December 18, 1993 revealed minor disc space narrowing at L4-5 but no fracture or dislocation was seen.”
File records show that the worker underwent treatment for both ankle injuries which included surgery. In 1996, he was awarded a 30% permanent partial impairment award for decreased range of motion in both ankles and a 2 inch shortening of his left leg.
In September 1998, the accident employer advised the WCB that the worker was losing time from work because of severe pain in his low back extending down his right leg.
An orthopaedic specialist reported on August 6, 1998 that the worker developed pain in the right posterior thigh radiating down from the low back of about 3-4 months duration. He indicated that the worker may have hurt his lower back in a work related accident a few years ago, however, the x-rays done in December 1993 showed no fractures. The x-rays also showed degenerative changes of L4-5. The diagnosis rendered by the specialist was “degenerative lumbar disc disease with sciatic right”.
A chiropractor’s first report dated August 18, 1998, indicated that the worker “initially fell off …pole in 93 – has only occasional episodes of low back pain since, but lately a major acute episode of low back pain.” His diagnosis of the worker’s condition was “… pinched nerve in lower back given severe sciatic R leg.”
In a doctor’s progress report dated August 25, 1998, the attending physician noted that the worker complained of severe low back pain with associated spasm and pain radiating to the posterior right thigh. He diagnosed the worker’s condition as mechanical low back pain, paralumbar spasm and to rule out scoliosis (disc protrusion).
The file information was reviewed by a WCB medical advisor at the request of primary adjudication. The medical advisor commented that the worker suffered from degenerative disc disease with right sided sciatica and that this condition was independent from the original compensable injury.
A sports medicine specialist assessed the worker on September 18, 1998. In his September 22, 1998 report, the specialist outlined his opinion that the worker had lumbar radiculopathy probably as a result of a disc herniation which was compressing one of his nerve roots.
On October 5, 1998, the worker underwent a CT scan of his lumbosacral spine. The results showed a large right posterior disc herniation at L5-S1.
In a report to the sports medicine specialist dated November 3, 1998, an orthopaedic surgeon wrote that he discussed with the worker whether he should undergo an L5-S1 right partial discectomy and laminotomy. This procedure was carried out in March 1999.
On December 16, 1998, a WCB medical advisor reviewed the file and stated that in his opinion, the worker’s L5-S1 disc herniation was not related to the compensable injury of October 1993.
In a report to the family physician dated September 22, 2004, an occupational health physician made the following comments following his review of the worker’s medical history:
“…there is a causal relationship between the 1993 accident that resulted in left leg shortness, required extended convalescence with muscle de-conditioning, and the onset of his back condition diagnosed as sciatica and successfully treated with surgery. There is no significant pre-existing condition related to the back that pertains to the issue. By my opinion the 1999 back injury is predominately attributable to the compensable injury and its course of treatment and convalescence.”
Lumbar spine x-rays were taken on December 17, 2004. The results showed “Lumbo-sacral degenerative disc changes. Finding of an old compression of L4.”
The worker was examined by a WCB orthopaedic consultant on December 17, 2004. Following his examination and review of the x-ray results, he opined that the worker’s back problems were unrelated to the compensable injury and that there was no enhancement or aggravation of a non work related pre-existing condition (memo dated January 28, 2005).
In an addendum to his examination notes of December 17, 2004, the WCB orthopaedic consultant stated, “…I note the claimant wears his shoe with a raise at all times when he is up. I feel this is adequate treatment for the leg length discrepancy. I doubt that the leg length discrepancy is significantly contributing to his back problems. Degenerative changes in the lumbar spine have been noted previously in 1993. I feel the claimant’s back discomfort is mainly due to these degenerative changes. Sequelae of the compression fracture of the L4 vertebrae may be also contributing to his back symptoms to a minor degree. His weight also could well be contributing to his back discomfort and knee problems.”
The worker was seen by a WCB impairment awards medical advisor on August 9, 2005. With regard to the worker’s back status he stated, “It is this writer’s opinion that his back problems, initially a compression fracture of L4, subsequent degenerative changes and compounded by his short left leg, are the direct result of the compensable injury; there being no past history of any back problem prior to that date. The chronic post-phlebitic syndrome of the left leg is likewise the result of prolonged recumbency with immobilization resulting in a deep vein thrombosis which has now re-canalized, which still requires treatment, again is considered to be a direct result of the compensable injury.”
A WCB senior medical advisor made the following comments after his review of the file on October 21, 2005: “Based on a review of the medical information on file, it is it is (sic) concluded that there is a causal relationship between the October 6, 1993 workplace accident and the L4 compression fracture… A mechanism to account for the mid 1998 L5-S1 disc herniation as occurring in relationship to the 1993 workplace accident has been proposed. In so far as the proposed mechanism is based on a series of speculations, a causal relationship is considered possible rather than probable.”
At the request of Review Office, a WCB orthopaedic consultant to Review Office was asked to review the file and offer his opinion as to the relationship between the L5-S1 disc protrusion and the 1993 accident. He stated on November 29, 2005, “It is possible that the claimant injured his L5-S1 disc at the time of his CI [compensable injury] in 1993 as well as sustaining a compression fracture of L4. It is not clear from review of the file when the L5-S1 disc may have herniated as it did not become symptomatic for neurological symptoms until June of 1998; necessitating subsequent surgery. The pre-existing degenerative changes at L4-5 & L5-S1; significant leg length discrepancy and subsequent ankle fusion are also contributing factors to his back symptoms.”
The Review Officer further spoke with the WCB orthopaedic consultant to Review Office on January 3, 2006 with respect to his comments of November 29, 2005. The Review Officer documented “The doctor said that it is possible that the worker injured (something less than a protrusion) his L5-S1 disc in his 1993 accident. He considers that moving beyond that statement would be entirely speculative and declined to comment on [the senior medical advisor’s] ‘possible rather than probable’ opinion. Notwithstanding the above, the doctor say (sic) that circumstances supported that there was not a relationship between the worker’s accident and his L5-S1 disc protrusion. There was an approximately five year gap between the accident and the onset of low back complaints consistent with a disc protrusion. Additionally, the worker was of an age when degenerative changes would be expected in the spine even in the absence of previous trauma. The doctor also noted that, although the spine works as a unit to a large degree, one would expect that if there was an injury to a disc at the time of his 1993 accident it would have been to the L4-L5 disc as that is where the compression fracture occurred. [The orthopaedic consultant] said that while the worker’s altered gait would no doubt cause his back to ache, it would not affect the discs.”
On January 3, 2006, Review Office determined that the worker’s L5-S1 back problems were not related to his October 1993 accident. In making this determination, Review Office relied on the opinions expressed by the WCB senior medical advisor and the orthopaedic consultant to Review Office. On January 2, 2007, the worker disagreed with Review Office’s decision and a hearing was arranged.
Reasons
Worker’s Position
The worker attended the hearing and made a submission regarding his claim.
The worker described the October 1993 workplace accident, his injuries and his recovery from the injuries. The worker advised that his left leg is significantly shorter than the right. He also advised that his spine has a gentle curve to the left as a result of the accident. He noted that he was hospitalized for three months. He had approximately 10 months of physiotherapy. In 1995 he had a left ankle fusion.
The worker advised that initially he used a wheelchair, then used elbow crutches for a couple years and followed by a cane. He is now able to walk without assists.
With respect to his back condition, he advised that at his PPI examination in 1996 he told the examining physician that he was having back pain. He also mentioned this to his orthopaedic surgeon in 1996 or 1997. He states that at this time he asked the orthopedic surgeon for lifts for his shoes as his left leg was shorter than his right leg. He was ultimately fitted with footwear with just under a two inch lift for the left foot.
He stated that the back pain subsided in 1997/1998 but returned in 1998 as he increased his walking and stopped using a cane. He had surgery on a herniated disc in March 1999. He said that he did nothing to cause the herniation other than resume normal activities. He believes that increasing his activity contributed to his worsening back condition.
He noted that in 1998 he advised the adjudicator about his increasing back pain. The adjudicator advised him to wear his special footwear at all times. Prior to this, he had not been instructed to wear the footwear all the time and was not wearing his footwear in the house.
The worker referred to various medical supports which supported his position including a report from an occupational health physician and a memo from the WCB physician who assessed him for a PPI.
The worker was asked whether he thought something happened in the 1993 incident that actually caused a particular injury to the L5-S1 area or whether the problem has arose from limping or the leg length discrepancy which resulted from the accident. The worker responded that in his opinion it was a combination of both plus the fact that he did not wear his special footwear all the time.
Analysis
The issue before the panel was whether the worker’s L5-S1 back problems are related to the October 1993 compensable accident. For the appeal to be successful the panel must find that the worker injured his L5-S1 area in the 1993 compensable accident or that the condition developed as a sequela of the compensable accident. The panel finds, on a balance of probabilities, that the L5-S1 back problem is caused by the 1993 compensable accident having likely developed as a result of the leg length discrepancy and significantly altered gait of the worker.
In making this decision the panel relies upon the opinion of the WCB impairment awards medical advisor who commented in a report dated August 9, 2005 that the worker’s back problems, initially a compression fracture of L4, subsequent degenerative changes and compounded by short left leg, are the direct result of the compensable accident.
The panel also relies upon the opinion of the occupational health physician who wrote on September 22, 2004 that the worker’s shortened leg constitutes a significant risk for developing back impairments and degeneration. The physician noted that the worker’s back pain and muscle spasm began in mid 1997 when he was resuming walking without elbow crutches. He concluded “…there is a causal relationship between the 1993 accident that resulted in the left leg shortness, required extended convalescence with muscle de-conditioning, and the onset of his back condition…”
The panel notes the worker’s evidence that he did not initially wear his orthotic footwear all the time. The worker advised the panel that it was not until 1998, upon the recommendation of WCB staff, when he began to wear the footwear around his house. The panel finds that not wearing the footwear contributed to the worker’s condition.
Finally, the panel understands that shortening of a leg and fusion of a joint can cause limping. The panel also understands that limping can have a biomechanical effect on the spine. This is caused by the shifting of body weight from the good leg to the shortened leg and results in a seesaw effect where the disc centres become the centres of rotation. As well, a curvature of the spine may result from the shortened leg. The panel understands that these biomechanical actions can cause or enhance degenerative changes. The panel finds, on a balance of probabilities, that the worker’s degenerative condition, specifically his L5-S1 back condition was caused or enhanced by his shortened leg, resulting curved spine and limping movement.
The worker’s appeal is allowed.
Panel Members
A. Scramstad, Presiding OfficerA. Finkel, Commissioner
M. Day, Commissioner
Recording Secretary, B. Kosc
A. Scramstad - Presiding Officer
Signed at Winnipeg this 10th day of April, 2007