CINDY R. HELSTROM, Employee/Appellant, v. ST. JOSEPH=S MED. CTR., SELF-INSURED, adm=d by BERKLEY RISK ADM=RS CO., Employer, and INSTITUTE FOR LOW BACK CARE, and REGIONAL DIAGNOSTIC RADIOLOGY, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
MAY 4, 2005
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including expert medical testimony, supports the compensation judge=s finding that the employee=s work injuries caused a temporary aggravation of the employee=s pre-existing neck condition and were not a substantial contributing cause of her ongoing neck condition, disability or need for treatment.
MEDICAL TREATMENT & EXPENSE. Where there is evidence in the record explaining what condition a medical device was used to treat, the compensation judge erred by denying the related medical expense for that device on the basis that the exhibit submitted did not indicate which condition it was used to treat. The denial is vacated and the matter remanded for reconsideration of the additional evidence.
Affirmed in part, vacated in part and remanded in part.
Determined by: Rykken, J., Stofferahn, J., and Pederson, J.
Compensation Judge: Gary P. Mesna
Attorneys: Michael G. Schultz, Sommerer & Schultz, Minneapolis, MN, for the Appellant. Edward Q. Cassidy and Karen M. Charlson, Felhaber, Larson, Fenlon & Vogt, St. Paul, MN, for the Respondents.
MIRIAM P. RYKKEN, Judge
The employee appeals the compensation judge=s findings that the employee=s cervical spine injury was a temporary aggravation of her underlying degenerative condition and was not a substantial contributing cause of her ongoing neck complaints, disability or need for surgery. The employee also appeals the compensation judge=s denial of medical expenses related to a lumbar traction device. In addition, on appeal, the employer filed a motion to supplement the record. We affirm in part, vacate in part, and remand a portion of the findings and order to the compensation judge for reconsideration. We also deny the employer=s motion.
On May 2, 2002, Cindy R. Helstrom, the employee sustained an admitted low back injury and an admitted cervical spine injury while working as an adult psychiatric nurse for St. Joseph=s Medical Center, the employer, which was self-insured for workers= compensation liability. In 1999, the employee, a registered nurse, had been assigned as a psychiatric nurse on the in-patient psychiatric unit at St. Joseph=s Hospital in Brainerd, Minnesota.
The employee previously had been treated for a low back condition in 1999, when Dr. Sunny Kim performed an L5-S1 laminectomy. The employee had an excellent result from that surgery and was able to work without any physical limitations. The employee testified that in 1999, she had undergone a pre-employment physical examination and was able to perform all the duties of her position without restrictions, pain, or treatment for her low back until her low back injury on May 2, 2002.
The employee=s position as a psychiatric nurse required her to be able to physically lift and restrain patients when needed. On May 2, 2002, the employee attempted to boost up a patient who was slumped in his chair, and whose restraining strap and catheter had been stretched taut. Immediately following this incident, the employee developed low back and leg pain. She also experienced pain and a burning sensation on the right side of her neck. The employee reported the injury and was treated at the emergency room at St. Joseph=s Medical Center, where the attending physician restricted her from lifting for one week and advised her to follow-up in one week if her symptoms did not improve. On May 28, 2002, the employee was treated by her family physician, Dr. Kathy Wimmer, for her low back symptoms and for pain and numbness in her right leg and foot. Dr. Wimmer=s chart note includes no reference to neck symptoms. However, a history questionnaire completed by the employee at a physical therapy appointment on June 5, 2002, includes a diagram showing that the employee had pain and burning in the neck region and pain in the mid back. On June 21, 2002, the employee saw Dr. Kim for her low back symptoms, reporting severe back pain and some numbness in the right foot, according to Dr. Kim=s chart note and a patient history questionnaire. The employee was treated with physical therapy and epidural steroid injections. A lumbar MRI indicated a bulge at L5-S1 with broad-based bulge effacement of both right and left neural foramina with possible small disc protrusion.
The employee returned to work with restrictions from August 8, 2002, through September 20, 2002. The employee was evaluated by Dr. Kim on September 20, 2002, and reported neck and upper extremity pain. In his chart note, Dr. Kim stated that he was unsure of the cause of the employee=s neck symptoms or condition, but Asince she has only had it for a few weeks, we will treat her conservatively.@ At that exam, the employee also reported to Dr. Kim that her leg pain had worsened, and so he recommended a lumbar epidural steroid injection and restricted the employee for a few days for further recovery.
The employee eventually attempted to return to work in her pre-injury position without restrictions, but continued to experience low back pain, burning, and numbness into her right foot, as well as neck pain. The employee was able to continue work until January 2, 2003, when she was pulled to the ground by an unruly and combative patient. That incident resulted in increased neck pain and pain radiating down her right arm, as well as increased low back symptoms. The employee again consulted Dr. Kim on January 7, 2003, who recommended a CT myelogram of the lumbar and cervical spine and cervical epidural steroid injections. The employee underwent the epidural steroid injections in the cervical spine but reported very minimal improvement.
On February 4, 2003, Dr. Kim interpreted the myelogram of the lumbar spine as showing a right-sided recurrent disc herniation with right S1 nerve root impingement; he interpreted the myelogram of the cervical spine as showing, most likely, a right-sided C5-6 disc herniation with right C6 nerve root impingement. Dr. Kim determined that the findings on the myelogram warranted a one-level cervical decompression and fusion at C5-C6, and that the employee would also require a repeat lumbar microdiskectomy to treat her persistent right leg pain.
In August 2003, the employee underwent a repeat right L5-S1 lumbar microdiskectomy. After that surgery, Dr. Kim recommended a low back rehabilitation program and gravity lumbar traction. On June 30, 2004, the employee underwent a cervical decompression and fusion at C5-C6, with allograft and instrumentation, also performed by Dr. Kim.
At the employer=s request, the employee underwent independent medical evaluations with Dr. Daniel Randa on November 14, 2002, and on March 1, 2004, and with Dr. Mary Dunn on October 31, 2003. In November 2002, Dr. Randa concluded that, as a result of her May 2002 work injury, the employee had sustained a temporary aggravation of her pre-existing lumbar condition that had resolved by the date of the examination and that she had not sustained any cervical spine injury. By March 2004, Dr. Randa concluded that the employee had sustained a L5-S1 disc herniation as a result of the May 2002 work injury and the aggravating injury in January 2003. He also concluded that the employee had pre-existing degenerative cervical spondylosis and reiterated his earlier opinion that the employee had not sustained a cervical spine injury in May 2002. His report contained no specific opinion concerning any causal relationship between the employee=s ongoing cervical spine condition and her injury on January 2, 2003.
In her report of December 4, 2003, Dr. Dunn diagnosed the employee=s neck condition as cervical degenerative disc disease of a long-standing, chronic nature, and expressed her opinion that the employee=s neck condition was unrelated to her May 2002 or January 2003 injuries. She concluded that the employee had changes in her cervical spine Athat would indicate a long-standing degenerative natural history course rather than an acute injury occurring either on May 2, 2002 or January 2, 2003.@ Dr. Dunn also found Ano consistent objective findings of cervical spine compressive disease that requires a surgical intervention.@ By contrast, Dr. Kim opined that the employee had sustained cervical spine injuries on May 2, 2002, and January 2, 2003, and testified that, in his opinion, the herniated disc at C5-C6 was caused by the employee=s injury of May 2, 2002, and was further aggravated by her January 2003 work injury.
On November 21, 2002, the employee filed a medical request and claim petition, claiming temporary total disability benefits from and after September 18, 2002. On January 23, 2003, the employer filed a petition to discontinue benefits, alleging that the employee=s May 2, 2002, injury was a temporary injury. On February 11, 2003, the employee filed an amended claim petition alleging a second injury on January 2, 2003, and claiming wage loss benefits. The employer disputed the nature and extent of the May 2, 2002, neck injury and denied a cervical spine injury on January 2, 2003. On March 24, 2003, the employee amended her claim to include a claim for benefits based on 14% permanent partial disability of the whole body, related to her lumbar spine injury. All of the pleadings were consolidated for hearing.
On June 11, 2003, the parties entered into a partial stipulation for settlement in which the employer admitted that the employee had sustained a permanent aggravation of a pre-existing lumbar spine condition, and agreed that a lumbar microdiskectomy, as recommended by Dr. Kim, was reasonable and necessary treatment to cure or relieve the effects of the May 2, 2002, injury. The employer also stipulated that the employee sustained a cervical spine injury on May 1, 2002, the nature and extent of which was in dispute. As part of the partial stipulation for settlement, the employer withdrew its petition to discontinue benefits.
A hearing was held on July 13, 2004, regarding the nature and extent of the employee=s cervical spine injury, medical expenses related to the employee=s spine condition, including the surgery to her cervical spine, temporary total disability benefits, and medical expenses related to the use of a lumbar traction device. In his findings and order issued on September 10, 2004, the compensation judge found that, as a result of her May 2, 2002, injury, the employee had sustained a brief temporary aggravation of her underlying degenerative neck condition but that the injury was not a substantial contributing cause of the employee=s ongoing neck complaints, disability, or the need for neck surgery or other medical care. The compensation judge also found that the employee did not sustain a significant injury to her neck on January 2, 2003. He concluded that A[a]t most, she had a brief increase in neck pain as a result of the incident. The incident was not a substantial contributing cause of her ongoing neck complaints.@ The compensation judge concluded that the employee=s June 20, 2004, cervical spine fusion surgery was not related to her work injuries, denied temporary total disability benefits from June 18, 2004, through the date of the hearing, and denied payment for medical bills related to the cervical spine surgery. The compensation judge also denied the employee=s claim for payment of expenses related to the lumbar traction device, finding that it was not clear from the record which condition the device was used to treat. The employee appeals.
STANDARD OF REVIEW
On appeal, the Workers= Compensation Court of Appeals must determine whether Athe findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@ Minn. Stat. ' 176.421, subd. 1. Substantial evidence supports the findings if, in the context of the entire record, Athey are supported by evidence that a reasonable mind might accept as adequate.@ Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, A[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Findings of fact should not be disturbed, even though the reviewing court might disagree with them, Aunless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Id.
The employee argues that there is no substantial evidence in the record to support the compensation judge=s finding that her May 2, 2002, work injury caused a brief temporary aggravation of her pre-existing neck condition and was not a substantial contributing cause of her ongoing neck condition, disability or need for treatment. The employee argues that before her 2002 work injury, she was able to work without restrictions and that she had no neck pain, while she has had neck pain ever since that injury. The employee argues that she reported her neck symptoms to her medical providers following the 2002 injury, and specifically points to the physical therapy history questionnaire which indicates that she reported neck pain to the therapist on June 5, 2002.
The compensation judge, however, was not persuaded that any neck pain reported on June 5, 2002, was necessarily caused by the May 2, 2002, work injury. While Dr. Kim opined that the employee had sustained cervical spine injuries on May 2, 2002, and January 2, 2003, the compensation judge relied upon Dr. Randa and Dr. Dunn=s opinions that the employee had degenerative disc disease in her neck which was only temporarily aggravated by the 2002 work injury. It is the compensation judge's responsibility, as trier of fact, to resolve conflicts in expert testimony, Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985), and, in this case, the compensation judge relied on the opinions of Drs. Randa and Dunn. In addition, according to Dr. Kim=s chart note, the employee did not treat with Dr. Kim for her neck until September 2002. Substantial evidence supports the compensation judge=s finding that the employee=s May 2, 2002, work injury caused a temporary aggravation of her pre-existing neck condition and was not a substantial contributing cause of her ongoing neck condition, disability or need for medical treatment and surgery. We affirm that finding.
The employee also argues that she sustained a permanent aggravation of her neck condition as a result of her January 2003 work injury. The compensation judge found that the January 2, 2003, work injury did not cause a significant worsening of her neck condition since she had reported significant pain in December 2002 and reported similar complaints in January 2003 after the second work injury. The compensation judge found that although the employee was involved in an incident with a patient in January 2003 in which the patient pulled the employee down, that Aincident did not cause a significant worsening of her neck condition@ and that, at most, the employee Ahad a brief increase in neck pain as a result of the incident.@ Although the record includes Dr. Kim=s opinion that the 2003 incident aggravated the cervical disc herniation that was originally caused by the 2002 work injury, the record also contains the medical opinion of Dr. Dunn, who specifically opined that the employee=s cervical degenerative disc disease was of a long-standing, chronic nature, unrelated to her May 2002 or January 2003 injuries. Because the record contains adequate medical evidence to support the compensation judge=s finding that the January 2003 work injury was not a substantial contributing cause of the employee=s ongoing neck condition, disability or need for treatment, we therefore must affirm that finding as well.
Since we have affirmed the compensation judge=s findings that the May 2002 and January 2003 work injuries were not substantial contributing causes of the employee=s ongoing neck condition, disability or need for treatment, we need not address the employee=s arguments regarding the reasonableness and necessity of the employee=s cervical spine surgery or her entitlement to temporary total disability benefits related to the surgery.
The employee also argues that the compensation judge erred by denying certain medical expenses. An employee has the burden of proving that his or her claimed medical expenses were reasonable, necessary, and causally related to his or her work injury. See, e.g., Adkins v. University Health Care Ctr., 405 N.W.2d 233, 39 W.C.D. 898 (Minn. 1987). Most of the medical expenses claimed were related to the employee=s cervical spine condition, and given our affirmance of the compensation judge=s finding that the cervical spine condition was not causally related to the employee=s work injuries, we affirm the compensation judge=s denial of those expenses.
The compensation judge also denied expenses related to a traction device, the LTX 3000, on the basis that the bill submitted as an exhibit did not indicate for which condition it was used to treat. Dr. Kim=s records from late 2003 refer to gravity lumbar traction, and Dr. Kim=s chart note of January 28, 2004, states that the employee reported excellent benefit from the gravity lumbar traction. In addition, the employee testified at length about how the traction device was used to treat her lumbar condition. It is clear from the record that the device was related to treatment for the employee=s lumbar spine condition. We therefore vacate the compensation judge=s finding that it is not clear from the record what the LTX 3000 device is or for what it was used, and we also vacate the judge=s related denial of the medical expense claimed for the lumbar traction device. We remand that claim to the compensation judge for reconsideration; the compensation judge may require additional testimony and submission of exhibits as he deems necessary.
 On December 10, 2004, the self-insured employer filed a motion to supplement the record by a statement of proceedings if necessary for this court to review the case. The employer filed the motion because the transcript in this case is incomplete, according to the court reporter=s note on pages 61-62 of the transcript and due to a malfunction of the hearing recording equipment. The employee=s direct testimony is included in the transcript but a portion of the employee=s cross-examination was not recorded. The record contains sufficient exhibits and testimony for our review. Therefore, we deny the motion to supplement the record.
 The first report of injury filed after the employee=s initial injury, as well as some earlier documents filed at the Department of Labor and Industry and the Office of Administrative Hearings, identify the date of the employee=s initial injury as May 1, 2002. However, the employee testified she believed the injury was on May 2, 2002, and the compensation judge found the injury date to be May 2, 2002. There is no dispute that an injury occurred on either May 1 or May 2, 2002. As such, we have used the May 2, 2002, date to identify the 2002 injury date.
 Both Drs. Randa and Dunn also addressed the employee=s lumbar spine condition and her related disability and need for medical treatment, although the employee=s lumbar spine injuries are not at issue in this appeal.