RONALD STREHLER, Employee/Appellant, v. NAPCO INDUS., and ST. PAUL TRAVELERS INS. CO., Employer-Insurer, and MEDICAL ADVANCED PAIN SPECIALISTS, Intervenor.
WORKERS= COMPENSATION COURT OF APPEALS
OCTOBER 9, 2006
MEDICAL TREATMENT & EXPENSE - REASONABLE & NECESSARY. Substantial evidence, including the well-founded opinion of the independent medical examiner, supports the compensation judge=s finding that the treatment provided by Medical Advanced Pain Specialists to the employee was not reasonable or necessary, and the compensation judge=s denial of a trial of a spinal cord stimulator and/or pain pump recommended by the employee=s treating physician.
Determined by: Johnson, C.J., Rykken, J., and Stofferahn, J.
Compensation Judge: Cheryl LeClair-Sommer
Attorneys: Michael G. Schultz, Sommerer & Schultz, Minneapolis, MN, for the Appellant. Thomas A. Atkinson, John G. Ness & Associates, St. Paul, MN, for the Respondents.
THOMAS L. JOHNSON, Judge
The employee appeals from the compensation judge=s finding that medical treatment provided by Medical Advanced Pain Specialists (MAPS) was not reasonable or necessary, and from the judge=s denial of a recommended trial of an implanted spinal cord stimulator and/or pain pump. We affirm.
Ronald Strehler, the employee, sustained a personal injury to the lumbar spine on April 6, 1978, while working for NAPCO Industries, the employer, then insured by St. Paul Travelers Insurance Company. The employer and insurer admitted liability for the employee=s injury.
In 1981, the employee saw Dr. Andrew Smith, a neurosurgeon, who diagnosed a herniated lumbar disc and performed a lumbar hemilaminectomy at L4-5 on the right. Following surgery, the employee underwent a course of physical therapy, and in September 1981, Dr. Smith released the employee to return to work without restrictions.
In 1984, the employee saw Dr. Robert Wengler complaining of recurrent episodes of acute back pain. A CT scan of the lumbar spine showed the postoperative laminectomy at L4-5 with a possible recurrent disc herniation and a moderately large disc herniation at L5-S1 on the left with mild left S1 nerve root compression. Dr. Wengler performed chemonucleolysis at both levels.
The employee continued to complain of low back and left leg symptoms and, in 1986, saw Dr. Alexander Lifson at the Institute for Low Back Care. The doctor diagnosed discogenic mechanical low back pain syndrome and referred the employee for physical therapy. By April 1987, Dr. Lifson stated his physical examination was quite unremarkable with minimal limitation of range of motion. The doctor stated the employee could continue working with no limitations.
In September 2004, the employee was seen by Dr. David Schultz at Medical Advanced Pain Specialists (MAPS) on referral from Dr. Bryan Nelson, his family physician. The employee gave a history of continuous low back pain since 1978, and was then taking Vioxx and Tramadol for pain. Following an examination, the doctor performed an epidural steroid injection at L4-5 that did not provide any lasting relief. In October 2004, the doctor provided lumbar facet joint injections at L3-4, L4-5 and L5-S1 that reduced the employee=s pain level for a short time but provided no lasting relief. In December and January 2005, the doctor provided caudal steroid injections which again provided temporary pain relief only. In March 2005, Dr. Schultz prescribed Tylenol with codeine and gabitirl for pain management and an intra-articular right-left sacroiliac joint injection. In July 2005, the doctor provided a medial branch block injection from which the doctor concluded the employee=s pain was not coming from the facet joints because he had no dramatic pain relief from the branch block. The employee was last seen at MAPS on October 6, 2005, at which point he had just finished a trial of MS Contin, a morphine derivative, which the employee stated did not help him much. Dr. Schultz then recommended implantable pain control therapy trials.
Dr. George Kramer, a physiatrist, examined the employee in July 2005 at the request of the employer and insurer. The doctor obtained a history from the employee, reviewed the employee=s medical records and performed a physical examination. The doctor diagnosed mechanical low back pain with no evidence of neuropathic or radicular pain. In response to the question of whether the employee=s treatment at MAPS was reasonable and necessary medical care, Dr. Kramer responded:
The referral to MAPS was not necessary nor reasonable for the type of pain he described. He had low back and buttock pain only, no neuropathic pain, and was managed on low dose tramadol four per day. That degree of pain managed well with tramadol and no evidence of neuropathic pain would not be an indication for a nerve stimulator. Epidural injections were not indicated. Facet injections for mechanical low back pain x 1 would be reasonable but not necessary again due to the manageable level of pain at that time. Subsequent repeat facet injections and a trial of an implantable nerve stimulator would certainly not be indicated. The work comp guidelines specifically indicate use of implantable nerve stimulations or morphine pumps only after extensive trials of other treatments have been exhausted and neuropathic pain is intractable, neither of which conditions exist, and after a psychological evaluation and second opinion. Treatment guidelines 5221.6200 Subp 6,C (1) (2).
Moreover, the treatment specifically at MAPS was not related to the April 1978 injury. Within a reasonable degree of medical certainty, he had managed his back pain with low dose medication. He had not continued on an exercise program which had been helpful in the past, and had he reinstituted an active rehabilitation program, his symptoms likely would have improved.
(Resp. Ex. 15.)
The deposition of Dr. Schultz was taken in October 2005. The doctor=s diagnosis of the employee=s condition was chronic lumbar radiculopathy and lumbar spondylolysis causing intractable low back and buttock pain. Dr. Schultz opined the employee=s April 1978 injury was a substantial and contributing cause of the employee=s condition and pain. Dr. Schultz stated the different types of interventional injections performed at MAPS had both a diagnostic and therapeutic purpose. Dr. Schultz opined the treatment provided at MAPS was reasonable and necessary to cure or relieve the employee from the effects of his personal injury. The doctor noted in chronic pain patients, like the employee, there are few treatment options. The doctor stated the employee was not a candidate for further surgery, and the injections and medications were not successful, so a spinal cord stimulator and/or pain pump should be explored. The doctor acknowledged Athe injections didn=t really lead for a perfect diagnosis and they also didn=t lead to a reduction of pain. That=s why we=ve recommended implantable pain therapy trials to see if that would be a better option for him.@ The doctor recommended trial of a temporary stimulating device for one week to determine whether it reduced the employee=s pain.
The employee testified since 1988 he has used a whirlpool to treat his low back and swims for exercise. In addition, he does back exercises when he feels capable. He testified the treatment he received at MAPS enabled him to continue working and stated he would be unable to work without the pain medication.
The employee filed a medical request seeking payment of the unpaid balance for treatment at MAPS and seeking approval for a trial of a spinal cord stimulator and/or pain pump. Following a hearing, the compensation judge found the medical treatment provided by MAPS and the recommendation for a trial of a spinal cord stimulator was not reasonable or necessary medical treatment. The employee appeals.
The employee appeals the compensation judge=s finding that the medical treatment rendered at MAPS was not reasonable and necessary. He contends that despite two surgeries and conservative treatment he continues to experience chronic low back pain together with right foot numbness and a foot drop. The treatment at MAPS, the employee contends, was a reasonable attempt to diagnose, manage and relieve his chronic back pain. Given the chronicity of symptoms, the failure of surgery and conservative care up to the time the employee was seen at MAPS, the employee contends the injections and medications prescribed by Dr. Schultz were reasonable and necessary medical treatment. We are not persuaded.
Dr. Kramer was unequivocal in his opinion that the treatment the employee received at MAPS was not reasonable and necessary treatment for the type of pain described by the employee. Dr. Kramer opined the employee did not have neuropathic pain and concluded his low back pain was managed on low dose Tramadol. Dr. Kramer obtained a history from the employee, reviewed the relevant medical records and performed a physical examination. As a general rule, this level of knowledge is sufficient to afford foundation for the opinion of a medical expert. See, e.g., Caizzo v. McDonald=s, 65 W.C.D. 378 (W.C.C.A. 2005). The compensation judge adopted and relied on the opinions of Dr. Kramer in concluding the medical treatment at MAPS was not reasonable and necessary. The opinions of Dr. Kramer were adequately founded and the compensation judge could reasonably rely upon them. Accordingly, substantial evidence supports the compensation judge=s decision and that decision must be affirmed. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 37 W.C.D. 235 (Minn. 1984).
The employee also appeals the compensation judge=s denial of his request for a trial of a spinal cord stimulator and/or pain pump. Dr. Schultz testified the goal of the spinal cord stimulator or pain pump was to reduce the amount of medication used by the employee to allow him to work and be comfortable. A successful trial of an external spinal cord stimulator, Dr. Schultz stated, would dramatically reduce the employee=s pain and allow him to function better physically. The employee argues he has exhausted both surgical and conservative treatment and a trial of a stimulator or pain pump is appropriate given the severity and chronicity of his symptoms. For these reasons, the employee asks this court to reverse the compensation judge=s denial of the recommended trial of the spinal cord stimulator or pain pump.
Certainly, the medical reports and testimony of Dr. Schultz would support an award of a trial of a stimulator or pain pump. The issue before the court, however, is not whether the evidence will support a different result. The issue on appeal is whether the factual findings are Aclearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@ Minn. Stat. ' 176.421, subd. 1. The expert opinions of Dr. Kramer are directly opposed to those of Dr. Schultz. It is the compensation judge=s responsibility to resolve conflicts in expert testimony. See, Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).
Although Dr. Kramer opined such a trial was not reasonable or necessary, the employee contends his opinions lack foundation because the doctor mistakenly assumed the employee had no pain complaints from 1988 through 2004 and concluded the employee=s current complaints were of recent onset. We disagree. Dr. Kramer obtained a history from the employee of back pain off and on for years with increasing pain commencing in 2004. At the time of Dr. Kramer=s examination, the employee rated his pain at 7 on a scale of 1 to 10. Dr. Kramer reviewed the employee=s medical records and noted that from 1988 to 1991, there was no mention of low back pain in the records and stated there were medical records indicating the employee was asymptomatic between 1986 and January 1991. Dr. Kramer further noted there was no discussion of low back pain in multiple physical examinations in late 2001, 2002 and 2003. Dr. Kramer did not, as the employee asserts, conclude the employee had no low back symptoms from 1988 through August 2004. Rather, the doctor found that during that period there was no Asignificant evidence of low back pain in the medical record.@ (Resp. Ex. 15.) This is a reasonable interpretation of the medical records.
Dr. Kramer had adequate foundation for his opinions and the compensation judge could reasonably rely upon them. Accordingly, the compensation judge=s denial of the recommended trial of a spinal cord stimulator and/or pain pump is affirmed.
 Blue Cross Blue Shield made payment to MAPS but did not intervene in this proceeding.