The employer and insurer appeal from the compensation judge=s determination that the employee=s personal injury of October 28, 1994 was a substantial contributing cause of the em­ployee=s cervical symptoms and her need for care and treatment to the cervical spine.  We affirm as modified.  The employer and insurer also appeal the compensation judge=s award of payment for sur­gical consultations in 2000 and 2001, and the judge=s finding that the em­ployee=s cranial and full-spine MRI scan and hospitalization to stabilize the employee=s non-work-related pul­monary con­dition were reason­able, necessary and causally related to the employee=s personal injury.  We affirm in part and reverse in part.

BACKGROUND

Cheryl Arnold, the employee, began working as a nursing assistant for the employer, Franciscan Health Center (then known as Surf and Sand Health Center) in 1983.  On October 28, 1994, the employee slipped on sheets obscuring a bed crank, tripped and fell, and landed against a radiator on her out­stretched right arm.  The employer and insurer admitted liability for an injury to the right arm and shoulder, and paid various workers= compensation benefits to the employee.

The employee was seen at St. Luke=s Occupational Medi­cine, on the day of the injury, with multiple contusions of the right arm.  She was referred for physical therapy, and released to return to work on limited duty.   On November 22, 1994, Dr. Katherine Kostamo noted trigger points in the right trapezius muscle and continuing right shoulder pain.  By letter dated November 25, 1994, the physical therapist indicated the employee had completed 12 sessions with little progress, noting acute pain on palpation in the right deltoid and upper trapezius muscles.

The employee was seen by Dr. Daniel Wallerstein, on Nov­ember 30, 1994, at the request of Dr. Kostamo, for a physical medicine consultation.  The employee described a burning sensation in the lower cervical and upper trapezius muscles and lateral aspect of the left arm, as well as shoot­ing pain down the right arm.  Cervical range of motion was limited on examination.  Dr. Wallerstein recommended continued physical therapy and advised the employee to avoid co-contrac­tion of the cervical and upper thoracic/shoulder soft tissues.

The employee did not improve with physical therapy, but continued to experience ten­derness and pain in the paracervical, trapezius, rhomboid, and supraspinatus muscles in the neck and upper back, along with significant pain over the anterior capsule of the right shoulder.  On December 28, 1994, Dr. Kostamo ordered an MRI scan of the right shoulder which showed a full thickness rotator cuff tear.  On January 13, 1995, the employee was ex­amined by Dr. Peter Goldschmidt, an orthopedic surgeon, who recommended surgical repair of the rotator cuff. 

The employee had suffered for many years from advanced chronic obstructive pul­monary disease (COPD), severe asthma and sleep apnea syndrome and was, therefore, at increased risk for any surgery.  She was examined by her pulmonologist who stated the em­ployee was the most stable he had seen in the recent past, and was in suitable condition for the proposed surgery.  On January 26, 1995, Dr. Goldschmidt performed a rotator cuff repair and partial acromioplasty of the right shoulder under regional block anesthesia.

Following recovery from the surgery, the employee received extensive physical therapy to improve her strength and range of motion.  After some initial improvement, she failed to make fur­ther gains.  In late July 1995, Dr. Goldschmidt noted the employee was losing tol­erance and was de­teriorating.  He referred the employee to Dr. Edward Martinson, a physical medicine and rehabili­tation specialist, for eval­uation and further treatment.

At the initial examination by Dr. Martinson on November 13, 1995, the employee report­ed constant pain in the neck and upper back with paresthesias in the right arm to the fingers.  Dr. Martinson diagnosed and treated the employee for a cervicothoracic strain, soft tissue thoracic outlet syndrome and myofascial pain resulting from biomechanical dysfunction secondary to her shoulder rehabilitation program.  The employee received extensive physical therapy and participated in a supervised exercise program.  The treatment resulted in eventual correction of her mechanical dys­function problem, but the employee continued to have considerable pain in her shoulders, right great­er than left, and persistent myofascial neck and upper back pain.  On July 29, 1996, Dr. Martinson concluded the employee had reached maximum medical improvement for her secondary neck and upper back strain, provided permanent work restrictions, and assigned a 3.5 percent permanent partial disability rating for the cervical strain.

Over the next several years, the employee experienced periodic exacerbations of shoulder, upper back and neck pain for which she received physical therapy treatment.  On August 25, 1998, Dr. Martinson indicated he had exhausted conservative management options and had no further recommendations, releasing the employee to return for care as needed.  During this period of time, the employee also experienced worsening COPD and asthma symptoms requiring increased use of Prednisone and resulting in several hospitalizations to treat acute exacerbations of her COPD.

On January 13, 1999, the employee was seen by Dr. Jeffrey Klassen, an orthopedic sur­geon, on referral from her primary care physician, for evaluation of her chronic right shoulder and cervical myofascial pain.  An MRI arthrogram of the right shoulder, performed on February 1, 1999, showed a persistent rotator cuff tear.  Dr. Klassen was concerned about the potential for poor healing and infection given the employee=s Prednisone use, and referred the employee to Dr. Thomas Kaiser, a shoulder surgeon, for a second opinion.  Dr. Martinson concurred in the referral, citing Dr. Kaiser=s expertise in dealing with difficult shoulder problems.

Dr. Kaiser examined the employee on April 26, 1999.  He concluded the MRI arthrogram showed a definite rotator cuff tear of the supraspinatus tendon with osteoarthritic changes in the AC joint and spur formation on the anterior acromion.  He believed the employee had long-standing in­stability in the right shoulder, possibly due to incompleteness of the first surgery under regional block.  He concluded that surgery was an option, but would need to be done under general anes­thesia.  Dr. Kaiser observed the employee was at high risk because of her pulmonary problems, and referred her to her pulmonologist, Dr. Peter Franklin, to get her Ain shape@ for surgery.  Dr. Franklin ad­vised the employee she needed to stop smoking before undergoing surgery.  He prescribed Well­butrin, an antidepressant, and Habitrol patches to help her quit.

On September 3, 1999, Dr. Franklin noted the employee had stopped smoking in the last three to four weeks.  The doctor indicated it would be a good time to proceed with surgery, noting the employee was not having any kind of exacerbation and, with smoking cessation, was at or better than her usual base line.  The surgery was performed on September 10, 1999 by Dr. Kaiser with good results.  The employee began shoulder rehabilitation therapy a month later.  By the end of October 1999, Dr. Kaiser noted the employee was starting to get the same kind of symptoms in her arms and neck as before.

In January 2000, Dr. Kaiser obtained x-rays of the employee=s neck which showed nar­rowing and degenerative changes in the cervical spine, particularly at C5-6 and C6-7.  He referred the employee to physical therapy to set up home cervical traction and demonstrate neck range of motion exercises.  He also indicated that, since he did not treat necks, he preferred to refer the em­ployee to a physiatrist, such as Dr. Martinson, for further treatment.  An MRI study, performed on February 14, 2000, was significantly degraded due to motion of the employee during the scan, but confirmed the employee had arthritic findings and disc degeneration in the cervical spine.

The employee was seen by Dr. James Callahan, a neurosurgeon, at the request of Dr. Kaiser on March 8, 2000.  Dr. Callahan=s impression was multilevel degenerative disc disease and, according to the chart notes of Dr. Callahan and Dr. Kaiser, he did not believe the employee would benefit from surgery, in part at least, because of her pulmonary problems.  Dr. Kaiser indicated the em­ploy­ee might best be served by referral to a chronic pain management program.

On June 26, 2000, the employee returned to Dr. Martinson, at the urging of Dr. Kaiser, for consultation and treatment of her neck, upper back and arm complaints.  In the interim, the em­ployee had increasing problems with her COPD and asthma.  As a result, her fitness pro­gram was placed on hold for two months.  The employee described constant pain in the neck and upper back region with intermittent bilateral upper extremity paresthesias.  Dr. Martinson indicated he had ex­hausted conservative management options due to her low tolerance for physical activity.  The doc­tor further noted that Dr. Callahan=s chart note indicated the employee was not a sur­gical candidate, but the employee=s understanding of Dr. Callahan=s discussion with her following the consultation was different than what was described  in Dr. Callahan=s written report.  Given these circumstances, Dr. Martinson recommended that a final, second surgical opinion be obtained from Dr. Timothy Garvey at the Twin Cities Spine Center. 

Dr. Garvey examined the employee on August 14, 2000.  The doctor concluded that, clinically, the employee had symptoms compatible with cervical spondylosis with radicular pain.  Based on his review of the January 25, 2000 x-rays and the February 14, 2000 MRI scan, the doctor anticipated the C5-6 level would be the prominent feature, and if that was the case, there might be potential surgical options.  He requested further diagnostic testing, including a selective nerve block at C6 and a discography above and below the C5-6 level followed by a CT scan.  On October 16, 2000, Dr. Garvey advised the employee the testing showed de­gen­erative changes from C3 to C7 and that simple one-level surgical management was not an option, nor was she a candidate for a multi-level discectomy and fusion.  Dr. Garvey then referred the employee to Dr. Rockswold, a neuro­sur­geon, to rule out a congenital Chiari malforma­tion at the cranioverte­bral junction, noted on the employee=s February 14, 2000 MRI scan, as a possible cause of the employee=s paresthesias.  Dr. Garvey further recommended a new multi-spinal level MRI scan, under general anesthesia, to obtain a clear image not distorted by motion artifact and reliably assess possible spinal pathology.

The employee was seen by Dr. Rockswold on November 20, 2000.  The doctor concurred with the impression of degenerative disc disease with a probable disc protrusion at C5-6.  He doubt­ed the Chiari malformation was symptomatic, but, since the employee=s symptoms were compatible with such a problem, he agreed a repeat MRI scan under general anesthesia would be appropriate.

On November 24, 2000, the employee was admitted to Abbott-Northwestern Hospital for a cranial and full-spine MRI scan under general anesthesia.  Upon pre-operation examination, however, the employee was remarkably tachypneic,^[1] with pronounced bronchospasm and very low oxy­gen saturations.  She was re-admitted and hospitalized for aggressive treatment of an exacerba­tion of severe COPD with sinusitis and the MRI scan was Aplaced on hold@ until the COPD exacer­bation was under con­trol.  (Dep. E.M. 3: Dr. Bowen note 11/24/00; Dr. Harper letter 11/28/00.)   The em­ployee, subjec­tively, reported she was back at baseline on November 27, 2000, and had the MRI scan on that day.  She did well with the anesthesia from a respiratory standpoint and was dis­charged from the hospital the following morning.

The employee returned to see Dr. Garvey on February 5, 2001.  He informed the em­ployee that Dr. Rockswold concluded the Chiari malformation was not a significant neurological lesion.  Based on her complex medical circumstances and multi-level degenerative spine disease, Dr. Garvey did not believe surgical intervention was an option for the employee and recommended a chronic pain approach to treatment of her neck and arm pain and paresthesias.  Unfortunately, the employee died as a consequence of her severe COPD and asthma on February 24, 2001.

The employee filed a Medical Request on May 18, 2000, seeking payment of expenses incurred for diag­nosis and treat­ment of her cervical problems.  The employer and insurer denied liability, assert­ing the employee=s 1994 personal injury to the right shoulder was not a substantial contributing factor to the employee=s need for medical care related to the cervical spine.  The matter was heard by a compensation judge at the Office of Administrative Hearings on June 11, 2001.  In a Findings and Order, served and filed October 15, 2001, the compensation judge found the October 28, 1994 work-related injury was a substantial contributing cause of the employee=s cervical symptoms and her need for care and treatment to the cervical spine.  The judge further held that all of the medical care and treatment provided to the employee, including the cranial and full-spine MRI scan, and the treatment provided at Abbott Northwestern Hospital to stabilize her pulmonary condition, was rea­sonable and necessary as a direct result of her 1994 personal injury.  The employer and insurer appeal.

DECISION

Causation: cervical complaints and treatment

The employer and insurer contend that substantial evidence does not support the compen­sation judge=s finding of a causal relationship between the employee=s cervical symptoms and com­plaints and the admitted October 28, 1994 right shoulder injury.  They assert that all treatment with medical providers between the date of injury and January 1, 2001 was sought relative to the em­ploy­ee=s right shoulder rotator cuff tear and there is insufficient evidence of a work-related injury to the cervical spine.   We disagree.

The medical records reflect complaints of cervical, upper back and arm pain and pares­thesias, along with findings of muscle tightness and tenderness, beginning in Nov­em­ber 1994.  Fol­lowing the first shoulder surgery, the employee was referred to Dr. Martinson spe­cifi­cally for evalu­ation and treatment of her ongoing neck, upper back and upper extremity symp­toms.  Dr. Martinson diagnosed and treated the employee for a cervicothoracic strain, soft tissue thoracic outlet syndrome and myofascial pain secondary to her right shoulder injury.  On July 29, 1996, Dr. Martinson assign­ed a 3.5 per­cent permanent partial disability rating for the employee=s neck strain.  The em­ployer and insurer paid for medical care and treatment to the employee=s neck and upper back as well as the cervical strain/sprain per­manency assigned by Dr. Martinson.

Following recovery from her second shoulder surgery in September 1999, the employee=s neck, upper back and arm symptoms returned and she was again referred to Dr. Martinson for eval­uation and recommendations for treatment.  At his deposition, Dr. Martinson testified that it was his impression that the employee=s neck and upper back problems had not significantly re­gressed after the second surgery, they just had not improved, and she continued to have the same cycle of pain. (Dep. at 71.)  Dr. Martinson further testified, that in his opinion, the employee=s neck and upper back symptoms were secondary to and a consequence of her right shoulder injury, explaining that while undergoing rehabilitation from the shoulder injury, the employee developed abnormal movement and muscle contraction patterns causing musculoskeletal and chronic myofascial-type symptoms in her neck and upper back, complicated by the employee=s COPD and asthma.  (Pet. Ex. E.)

The employer and insurer contend, however, there is no evidence of a Atraumatically in­duced@ injury, nor any objective findings consistent with an injury to the cervical spine, and that in the absence of such evidence there cannot be a finding of a work-related cervical spine injury.  We are not persuaded.  First, there is no requirement that an injury be established by Aobjective@ find­ings.  While objective medical evidence (such as x-rays, MRI scans or objective clinical tests) is neces­sary for an award of permanent partial disability (see Minn. Stat. ' 176.105, subd. 1), the existence of a com­pensable personal injury may be established based on the subjective complaints of an employee combined with the opinion of a medical expert that the employee sustained a work-related injury or aggravation.  Brown v. Minnesota Dep=t of Transp., 54 W.C.D. 60 (1996).  Here, the compensation judge accepted the opinion of Dr. Martinson along with ex­tensive medical records noting ongoing complaints of, and treatment for, neck and upper back pain and upper ex­tremi­ty paresthesias.

Second, it is well-established that every natural consequence flowing from an established work injury likewise arises out of the employment and is compensable.  Nelson v. American Luth­eran Church, 420 N.W.2d 588, 590-91, 40 W.C.D. 849, 851-52 (Minn. 1988).  Here, there was no claim of a separ­ate, traumatic injury to the cervical spine at the time of the October 28, 1994 incident.  Rather, the employee claimed an injury to the cervical and upper back region as a consequence of and secondary to treatment for her admitted right shoulder injury.^[2]  There is ample evidence to support the conclusion that the employee sustained a consequential injury to the cervical spine region as a complication of her work-related right shoulder injury.

Causal relationship, in determining the compensability of an injury or aggravation, is a question for the trier of fact.  Where medical experts differ, as they did here, resolution of the con­flict is to be resolved by the compensation judge.  Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D.181 (Minn.1994).  Substantial evidence supports the compensation judge=s finding of a causal relationship between the October 28, 1994 personal injury and the employee=s need for medical treatment to the cervical and upper back region, and we affirm.

Causation: surgical consultations and full-spine MRI scan

The employer and insurer contend the referrals to Drs. Callahan, Garvey and Rockswold were not causally related to the employee=s October 28, 1994 injury.  They assert Dr. Martinson had diagnosed a myofascial, soft tissue condition and there was no evi­dence of any aggravation to the cervical spine itself.  Under these cir­cum­stances, they argue, there is no basis for requiring the em­ployer and insurer to pay for any cervical spine sur­gical consultations.  The appellants further con­tend the purpose of the cranial and full-spine MRI scan of November 28, 2000, was to diag­nose a non-work-related con­genital Chiari malformation and/or a pre-existing cervical spine de­generative condition.  The ap­pellants argue that to impose liability, the conditions evaluated and tested must be causally related to the work injury.  We disagree.

This court has previously held that a referral to a medical specialist or for diagnostic test­ing to evaluate or rule out an alternative explanation or treatment for a work injury is com­pen­sable, whether or not the condition or diagnosis evaluated is, itself, work-related.  See, e.g., Reid v. Isanti Tire & Auto Care, slip op. (W.C.C.A. Apr. 9, 2002); Braatz v. Total Constr. and Equip., slip op. (W.C.C.A. May 19, 1992); Klaven v. Northwest Medical Center, slip op. (W.C.C.A. Sept. 24, 1991.)

The employee was seen by Dr. Callahan, a neurosurgeon, at the request of Dr. Kaiser,  for evaluation of neck pain and arm paresthesias following the second shoulder surgery.  Dr. Callahan stated he did not have anything to offer surgically and suggested referral to a chron­ic pain program.  After seeing Dr. Callahan, the employee returned to Dr. Martinson for treatment of her neck and arm complaints.  Due to the employee=s COPD and resulting low phy­sical activity toler­ance, Dr. Martinson felt he had exhausted conser­vative options.  He fur­ther testi­fied, that during the visit, it became apparent the em­ployee=s understanding of her discussion with Dr. Callahan was different from the conclusions expressed in the doctor=s written report.  Under these circumstances, and given the em­ployee=s complex medical situation, Dr. Martinson believed a referral for a second opinion was appropriate.  Dr. Martinson explained the em­ploy­ee continued to have problems despite an extensive course of treatment and he referred her to Dr. Garvey in an at­tempt to finally delineate and diagnose the source of her pain and symptoms and make a final de­termination whether the em­ployee might have a surgically treatable condition. AWe were dealing with the em­ployee=s neck and upper back pain and we were attempting to determine what was the etiology and whether there were treatment options for her.@  (Pet. Ex. at 77.)

Dr. Garvey, in turn, referred the employee to Dr. Rockswold, a neurosurgeon, for a con­sul­tation regarding a Chiari malformation at the craniovertebral junction noted on the February 14, 2000 MRI scan.  Dr. Rockswold  doubt­ed the Chiari malformation was symptomatic, but agreed the employee=s symptoms were compatible with such a problem and concurred with Dr. Garvey=s re­com­­men­dation of a repeat MRI scan under general anesthesia.  After reviewing the MRI scan, Dr. Rockswold concluded the Chiari malformation was not a significant neurological lesion.

There is no dispute the employee had pre-existing cervical spine degeneration nor that the Chiari anomaly was congenital, and had either been found symptomatic, the condition would not have been work-related.  However, the referrals to Drs. Callahan, Garvey and Rockswold and the cranial and full-spine MRI scan were clearly made to rule out possible alternative diagnoses and treatment for the employee=s work-related neck and upper back symptoms and complaints.  Sub­stan­tial evidence adequately supports the compensation judge=s award of reimbursement for these medi­cal expenses and we, accordingly, affirm.

Hospitalization at Abbott-Northwestern

Finally, the employer and insurer contend the employee=s hospitalization at Abbott-Northwestern for treat­ment of her COPD on and after November 24, 2000, was totally unrelated to the October 28, 1994 work injury, and argue the compensation judge erred in ordering them to pay for the hospitalization and related expenses.  We agree.

The employee was scheduled for the full-spine MRI scan, under general anesthesia, at Abbott-Northwestern Hospital.  When she arrived at the hospital for a pre-procedure physical ex­amination on November 24, 2000, the intake physician concluded she was experiencing an acute exacerbation of her severe COPD with sinusitis, and recommended hospitalization to aggressively treat the exacerbation.  The MRI scan was deferred.  It is clear from the medical records the em­ployee=s COPD and asthma had gradually worsened, and she had refused hospitali­zation or had been hospitalized for exacerbations of her COPD on several occasions in the recent past.  Although Dr. Martinson agreed that the employee=s COPD exacerbation was Aan issue that needed to be dealt with@ before placing the employee under general anesthesia, he did not in any way suggest the hos­pitalization for treatment of her pulmonary condition was causally related to her work injury or the MRI scan.

The fact the employee could not be placed under general anesthesia while experi­encing an acute exacerbation of her pre-existing, non-work-related COPD is not sufficient to provide the necessary causal relation between the employee=s work injury and her hospitalization.  The employee did eventually undergo the cranial and full-body scan on November 27, 2000 and was released from the hospital the following day.  We reverse the award of reimbursement and/or payment for the em­ployee=s hospitalization at Abbott-Northwestern, beginning November 24, 2000, for expenses related to treatment of the employee=s COPD exacerbation.  Payment for expenses incurred at Abbott-North­western Hospital for the cranial and full-spine MRI scan are affirmed.