Decision #56/11 - Type: Workers Compensation

Preamble

The worker fell at work on October 8, 2008 while folding tables. Her claim for compensation was accepted based on a low back strain and benefits were paid to March 26, 2009 when it was determined by the Workers Compensation Board ("WCB") that she no longer had a loss of earning capacity related to her compensable injury. The worker appealed the decision contending that her ongoing coccyx difficulties were related to the October 8, 2008 compensable injury. On November 18, 2009, Review Office confirmed that the worker was not entitled to benefits beyond March 26, 2009 and determined that there was no clinical objective anatomic explanation for the worker to have numbness and tingling in all her toes with radiation of pain into her left shoulder, neck and both legs in relation to a coccyx injury. The worker disagreed and an appeal was filed with the Appeal Commission with assistance from the Worker Advisor Office. A hearing was held on June 8, 2010 to consider the matter.

Issue

Whether or not the worker is entitled to wage loss benefits beyond March 26, 2009.

Decision

That the worker is not entitled to wage loss benefits beyond March 26, 2009.

Decision: Unanimous

Background

The worker reported that she injured her low back/tailbone area on October 8, 2008 when a folding lunch table she was lifting collapsed and she fell to the floor with it.

When seen for medical treatment on October 10, 2008, the worker indicated that she fell on her back/coccyx and hit her head while putting up tables at work. The diagnosis was inflammation at the coccyx area. When seen by a different physician at the same medical clinic on October 15, 2008, the worker was assessed with non-specific back pain with no ominous or neurogenic features and possibly an L5 radiculopathy.

The claim for compensation was accepted based on a back strain and benefits were paid to the worker commencing October 9, 2008.

On October 22, 2008, the worker was seen by a physiotherapist with complaints of low back pain, right greater than left, with a burning sensation over the tailbone and tingling into both legs. The diagnosis was “anterior rotated right ilium, suspect coccyx anteriorly displaced, hypersensitive posterior pelvis down into right leg.”

On October 29, 2008, the treating physician reported ongoing back and buttock pain and pain up into the neck area. He noted that the worker’s symptoms were challenging to objectively assess.

When seen for treatment on November 19, 2008, the attending physician noted ongoing pain in the lumbar and coccyx areas with no bruise or swelling, and that the pain radiated to the left shoulder and head. The physician reported, “difficult to assess objectively, will try Naprosyn, probably best to have WCB physician assess.”

On December 19, 2008, the worker was seen by a WCB medical advisor. The medical advisor indicated that the worker’s neck, left shoulder and headache complaints were not related to the accident of October 8, 2008. With regard to the lumbosacral spine and coccyx region, the examination revealed decreased lumbar range of motion and slightly decreased light sensation in the L3 and L5 dermatomes, more so on the right. There was normal strength and reflexes in both lower extremities and no evidence of swelling or inflammation in the low back. The medical advisor also noted enhanced pain behavior and positive Waddell signs. The medical advisor concluded that the worker appeared to have low back pain with no firm evidence of a radiculopathy.

The worker had an MRI of the lumbar spine on March 6, 2009 and the impression read as follows: “Negative for fracture or bone marrow edema. Anterior angulation at the tip of the coccyx is likely congenital. Slight disc bulging at L4-5. Probable hemangioma within L2.”

On March 13, 2009, the WCB medical advisor reviewed the MRI findings and stated: “At this point, no patho-anatomic abnormality has been identified to account for the reported symptomatology. There is no MRI correlate for the decreased light touch distribution and no radiological correlate for a radiculopathy. The anteriorly-angled coccyx is likely congenital, and is not likely a pain-generator. The hemangioma would not be the result of the CI [compensable injury], and the L4-5 slight disc bulge does not explain [the worker’s] symptoms. Given the above, there appears to be no pathoanatomic basis on which to restrict [the worker] in her work duties.”

In a decision dated March 18, 2009, primary adjudication advised the worker that wage loss benefits would only be paid to March 26, 2009 as it was felt that the medical information did not establish a cause and effect relationship between the accident of October 8, 2008 and her current reported difficulties.

On April 7, 2009, the worker’s treating physiotherapist wrote to the WCB stating that it was wrong for the WCB to abandon the worker at this point in time as she was still experiencing pain. The physiotherapist noted that the worker’s injury was a fall onto her tailbone. The MRI noted that the angulation of the coccyx and the hemangioma at the L2 vertebral body could be a contributing source of her ongoing pain.

On September 23, 2009, a worker advisor provided the WCB with a report from an orthopaedic surgeon dated September 8, 2009 to support that the worker’s ongoing tailbone difficulties were related to the October 8, 2008 compensable injury. The surgeon stated:

The patient gave a history of a work related injury in October 2008. She fell down on her buttocks when the tables she was folding up collapsed on to of (sic) her. She was aware of low back pain and leg pain. The leg pain is mostly related to the hip itself and there is no radiculopathy as such.

The patient does show some Waddell’s sign during investigation with an Oswestry score of 70/100 but which could not be verified on clinical evaluation. It is quite clear however that she cannot sit still, has to keep moving from one buttock to the other. She claims that she can stand no more then (sic) ten minutes.

On examination there was no neurological deficit as such but there are certainly localized tenderness over the coccyx itself. The x-ray were (sic) not really contributory regarding any acute injury to the lumbar spine but there was mild narrowing of the L5-S1 disc space. The CT scan which was then done regarding the coccyx itself shows mild osteoarthrosis of the sacrococcygeal joint with mild subluxation. This certainly could be the result of an injury.

Treatment to date therefore includes manipulation of the coccyx with infiltration of the sacrococcygeal joint. Hopefully this will control the pain…there is about 80% relief of symptoms on a permanent basis with this technique. If this should fail however, she will return for a coccygectomy…

At the request of primary adjudication, the new medical information was reviewed by a WCB medical advisor on October 5, 2009 and the following opinion was outlined:

· the mechanism of injury (falling on one’s buttocks from standing), was not one that would likely fracture or traumatize a coccyx, given the low amount of load experienced in such an incident.

· the MRI findings of anterior angulation of the coccyx was likely congenital based on the negative findings seen with the STIR sequence.

· when examined in December 2008, the worker complained of bilateral low back pain with radiation to the left shoulder and neck and into both legs. There was also numbness and tingling in all toes. These symptoms were not consistent with a coccyx injury. The December 2008 examination revealed tenderness to light superficial touch over the entire lumbosacral spine, buttocks, lateral thighs and left shoulder. Such discomfort was not consistent with a coccyx injury.

· a hemangioma is a benign vascular tumour which is not uncommon and is rarely symptomatic in the absence of spinal cord compression. In the worker’s case, there was no evidence on the MRI of spinal cord compression as a result of the hemangioma, and the symptoms described by the worker were unlikely due to a vertebral hemangioma.

· mild osteoarthrosis of the sacrococcygeal joint referenced by the treating orthopaedic surgeon would not cause the collection of symptoms described by the worker during the December 2008 examination, symptoms such as numbness and tingling of all her toes and radiation of pain into the left shoulder, neck and both legs.

· there was no patho-anatomic abnormality identified to account for the worker’s reported symptomatology and no workplace restrictions were required in relation to her compensable injury.

In a second decision dated October 6, 2009, primary adjudication confirmed that the worker’s current difficulties were not related to her compensable injury of October 8, 2008 based on the opinion expressed by the WCB medical advisor on October 5, 2009.

In a submission to Review Office dated October 15, 2009, the worker advisor outlined the opinion that on a balance of probabilities, the evidence supported that the worker sustained an injury to her pre-existing coccyx condition on October 8, 2009 and continued to experience symptoms that required additional treatment.

On November 18, 2009, Review Office confirmed that the worker was not entitled to wage loss benefits beyond March 26, 2009. Review Office agreed with the position taken by the WCB medical advisor and the worker’s own physician that there was no clinical objective anatomic explanation for the worker to have numbness and tingling in all her toes with radiation of pain into her left shoulder, neck and both legs in relation to a coccyx injury. Review Office felt that whatever was producing the worker’s subjective complaints of pain throughout so many areas of her anatomy did not have a relationship to her compensable injury of October 8, 2008.

On December 1, 2009, the worker advisor appealed Review Office’s decision to the Appeal Commission and an oral hearing was arranged.

On May 18, 2010, the worker advisor submitted reports from the treating orthopaedic surgeon dated July 28, 2009 and August 12, 2009 and an operative report dated January 8, 2010.

On June 8, 2010, a hearing was held at the Appeal Commission. Prior to determining the issue under appeal, the appeal panel requested additional information consisting of:

  1. Reports from the worker's family physician and orthopaedic surgeon.
  2. Examination by an independent medical examiner.
  3. Assessment by the WCB's Pain Management Unit.

Once the additional information was received at the Appeal Commission, the worker and the worker advisor were provided with copies and were asked to provide comment. On March 23, 2011, the panel met further to discuss the case and render its final decision.

Reasons

Applicable Legislation:

The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the Board of Directors.

Under subsection 4(1) of the Act, where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid to the worker by the WCB.

Subsection 39(1) of the Act provides that wage loss benefits will be paid: “…where an injury to a worker results in a loss of earning capacity…” Subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until such a time as the worker’s loss of earning capacity ends, or the worker attains the age of 65 years. Subsection 27(1) provides that medical aid will be paid by the WCB for so long as is necessary to cure and provide relief from the injury.

The worker’s position:

The worker was assisted by a worker advisor at the hearing. It was submitted that prior to the workplace accident of October 8, 2008, the worker was a very active, pain-free full-time employed person. Since the injury, she has consistently complained of difficulties in her tailbone area and right leg and continued to be under the care of her doctor for these conditions. To the date of the hearing, she had not returned to her pre-accident status and it was submitted that her ongoing difficulties were related, on a balance of probabilities, to the October 8, 2008 compensable injury.

Analysis:

The issue before the panel is whether the worker is entitled to wage loss benefits beyond March 26, 2009. The key question concerns whether the worker’s ongoing low back and leg difficulties are related to the workplace accident of October 8, 2008. After reviewing the evidence as a whole, we find on a balance of probabilities that the worker’s ongoing problems are not a result of the injury sustained in the October 8, 2008 accident and accordingly, the worker is not entitled to wage loss benefits beyond March 26, 2009.

The challenge the panel faced in considering this appeal was in determining whether the workplace accident caused or contributed to the surgical excision of the worker's coccyx. This surgery was performed after the worker's benefits had been discontinued by the WCB, and therefore the information on file about the procedure was not complete. The issue of causal relationship was considered by a WCB medical advisor on October 5, 2009; however, as this review was conducted prior to the January 8, 2010 operation, it did not have the benefit of the full medical record.

Following the hearing, the panel requested an orthopedic surgeon with no prior involvement in the claim to conduct an independent medical examination of the worker and to provide his opinion. The independent surgeon produced a report dated November 2, 2010 which stated the following conclusions:

  • [The worker] sustained a soft tissue injury to her lower back and pelvic area as a result of a work related injury August 8, 2008. Despite ongoing chronic pain, specific pathology in the axial skeleton including the lumbosacral spine, sacrum, coccyx and pelvis has not been uncovered.
  • The most probable diagnosis of the low back injury sustained October 8, 2008 was a soft tissue injury to the lower lumbar back region and sacrococcygeal region. At most there was a strain. There was no evidence of fracture, subluxation, dislocation or disc herniation or nerve root impingement.
  • The most probable diagnosis of her low back condition March 26, 2009 was a soft tissue injury, either sprain or strain, which would be causally related to her work place injury.
  • There was no specific identifiable pathology noted in the sacrum or coccyx on plain film x-rays or imaging CT or MRI. Therefore surgery on the coccyx would not have been required as a result of her October 8, 2008 injury.
  • Most probable diagnosis of [the worker's] current low back condition is chronic pain syndrome.
  • Her original injury would have been a soft tissue injury to the lower lumbar spine and sacrococcygeal area. No pathology has been uncovered to explain why a soft tissue injury would have become chronic. There is nothing present that would suggest that there is an adverse outcome to her coccygectomy surgery. Basically the manipulation, injections and coccygectomy did not help her chronic pain.
  • There is no other anatomical evidence to explain some unrelated cause for her chronic pain. Basically to date, time, multiple therapies and treatments and surgery have not changed [the worker's] persistent hypersensitivity and her chronic pain. To date, a specific cause of the hypersensitivity and chronic pain syndrome is not explained anatomically.

The panel feels that the independent orthopedic surgeon conducted a thorough analysis of the medical information and we accept his conclusions that the worker's compensable injury was limited to a soft tissue injury to lower lumbar spine and sacrococcygeal area and that the coccygectomy surgery was not required as a result of her October 8, 2008 accident.

The panel did note, however, that the orthopedic surgeon suggested a current diagnosis of chronic pain syndrome. As this is a psychological diagnosis, the panel then referred the worker for assessment by the WCB's Pain Management Unit, which specializes in assessment of pain conditions.

On February 3, 2011, the worker was interviewed and assessed by the WCB Pain Management Unit's medical advisor and psychological advisor. The psychological advisor's report of February 3, 2011 provided, in part, as follows:

This file was sent to the Pain Management Unit specifically with respect to the possible presence of Chronic Pain Syndrome, as had been suggested by one of her treating physicians. Chronic Pain Syndrome is not an official diagnosis in the DSM-IV or in any other diagnostic manual used in Psychiatry/Psychology. The term "Chronic Pain Syndrome" refers to a definition that had been developed and utilized by the Workers Compensation Board. Chronic Pain Syndrome was hypothesized to be related to a number of presenting symptoms.

The term Chronic Pain Syndrome and this definition are no longer being used at the WCB. Rather, the Pain Management Unit, as well as Psychology and Psychiatry at the WCB, utilizes diagnoses found in the DSM IV-TR. Therefore, in today's interview, it was the goal of the Pain Management Unit to determine if [the worker] is experiencing a Pain Disorder as per DSM criteria, given that Pain Disorder is the most similar diagnosis to the past definition of Chronic Pain Syndrome utilized by the WCB.

The Pain Management Unit does not opine that [the worker] is experiencing Pain Disorder, given the concern about the forthrightness and veracity of her reporting. As mentioned previously, there were significant contradictions, changes in reporting with respect to symptoms and location of symptoms, unusual reporting of symptoms and sometimes incongruent affect. There were contradictions within the interview and with respect to file material. The claimant also presented as responding in a vague and indirect manner to certain questions. Therefore, it is the determination of the Pain Management Unit that, on balance, no diagnosis of Pain Disorder is to be made.

The Pain Management Unit's opinion was based largely on concern about reliability of reporting. The panel notes that other medical practitioners who have examined the worker have similarly indicated the presence of pain exaggerations, clinical inconsistencies and some supratentorial issues. We therefore find, on a balance of probabilities, the evidence does not support a diagnosis of Pain Disorder with respect to the worker's current condition.

Based on the opinions of the WCB medical advisor (dated October 5, 2009) and the independent orthopedic surgeon, the panel finds that the worker's compensable injury was limited to a soft tissue injury and did not result in the need for the coccygectomy surgery. Although there was suggestion that the worker had developed a chronic pain syndrome as a result of this injury, the panel is not satisfied on a balance of probabilities that this diagnosis can be made. Regrettably, we must therefore find that the worker is not entitled to wage loss benefits beyond March 26, 2009. We thank the worker for her cooperation with the further and extensive investigation of her condition.

The worker's appeal is dismissed.

Panel Members

L. Choy, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 9th day of May, 2011

Back