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December 12, 2003
Mr. Fred Attorney
Attorney at Law
1234 Livinsgton Ave.
New Brunswick, NJ 08901
Re: Mr. Zolton Z. Top
Date of Injury/Onset: July 19, 2000
Dear Mr. Attorney,
On November 17, 2003, Mr. Z.Z. Top was seen in my office for an updated examination and evaluation of symptoms arising from a motor vehicle crash that he was involved in on July 19, 2000. Enclosed please find an updated narrative report, along with, impairment rating on the above patient.
DESCRIPTION OF INJURY:
Mr. Top reported being the restrained driver of a car that was hit on the left front side, by a car making a left turn. He immediately began to feel neck and arm pain.
The next day, July 20, 2000, he presented to my office for evaluation and treatment of his worsening symptoms.
INITIAL AND CURRENT SIGNS AND SYMPTOMS:
At the time of the initial consultation on July 20, 2000, Mr. Top complained primarily of sharp left sided neck pain, which radiated into the left shoulder. He also noted constant numbing pain in the left hand, most noted at the third through the fifth digits. He noted that the pain was initially so severe that he could not move his neck. He also noted aching pain in the mid back, and headaches.
At the time of the examination on November 17, 2003, Mr. Top complained primarily of pain in the neck and left shoulder, numbness in the third through fifth digits of his left hand, and notes that he still does not have much strength in his left hand. He specifically stated that he "cannot carry things with my left hand, that I can easily do with my right." He also noted difficulty sleeping due to the pain. Recently the pain has been shooting into his chest. So much so, that he sought a medical evaluation of his heart and lungs. EKG and chest films were taken, and found to be normal.
Mr. Top noted that his symptoms have continually worsened since the time of his last visit with me on July 18, 2002.
Mr. Top is a professional guitarist, who does over 100 dates per year. He has had difficulty playing his guitar, and has had to cancel several tour dates due to his injuries.
HISTORY:
Mr. Top indicated that he had not experienced prior symptoms similar to his current complaints, and was symptom free at the time of the aforementioned crash of July 19, 2000.
Mr. Top's history is not contributory. He notes a work related lower leg injury in April, 1999.
ACTIVITIES OF DAILY LIVING ASSESSMENT:
Based on an assessment of Mr. Top’s history, along with his subjective complaints, objective findings, radiographic analyses, and other test results, it is evident from a standpoint of medical certainty, that his current condition did result from the type of injury/onset described in this report. He reported suffering varying degrees of losses of functional capacity with the following activities:
With regard to Physical Activity, including standing, sitting, walking, bending, etc., Mr. Top stated: sitting, using a computer, and driving a car frequently aggravates his condition.
Mr. Top was forced to cancel several tour dates as a professional guitar player following the accident.
Recently, Mr. Top has developed acute chest pain, which is radiating from his upper back on the left side. This pain interferes with his ability to get a normal night's sleep.
GENERAL PHYSICAL EXAMINATION:
Mr. Top is a right handed 37 year-old mentally alert and cooperative male, who appeared to be in significant discomfort. Neck movements were noted to be painful, especially at the limits of motion.
Date of Birth: June 6, 1966.
Weight: 130 pounds. Height: 5 feet 9 inches.
Deep Tendon Reflexes: The left and right Biceps, left and right Triceps and left and right Brachioradialis tendons presented a normal reflex.
RANGE OF MOTION STUDIES:
The following joint range of motion calculations and analyses are based upon the methodologies and tables found in the A.M.A. Guides to the Evaluation of Permanent Impairment, 4th Edition.
At the time of the examination on November 17, 2003:
Cervical Spine: Angle Analysis
Flexion 45 degrees No restriction: norm is 45-50 degrees.
Extension 40 degrees Mild restriction: norm is 60 degrees.
Left Lateral Flexion 45 degrees No restriction: norm is 45 degrees.
Right Lateral Flexion 35 degrees Moderate restriction: norm is 45 degrees.
Left Rotation 65 degrees Mild restriction: norm is 80 degrees.
Right Rotation 60 degrees Mild restriction: norm is 80 degrees.
Grip Strength Evaluation:
The following measurements were obtained using a Jamar Dynamometer. Three readings of the involved hand are averaged and compared to those of the opposite hand, which is usually normal. If both extremities are involved, the strength measurements are compared to the average normal strengths listed in Tables 31 and 32 on pages 64 and 65 of the A.M.A. Guides to the Evaluation of Permanent Impairment.
Left Hand: 15, 17, 18 Avg: 16.7 kilograms.
Right Hand: 35, 40, 37 Avg: 37.3 kilograms.
Utilizing the A.M.A. Guides' 'Strength Loss Index' Formula from page 65, which is Normal Strength minus Abnormal Strength divided by Normal Strength equals % Strength Loss Index: (Using Right hand as the "normal" grip Strength)
Left Hand: (37.3 - 16.67) divided by 37.3 = 55% Strength Loss Index.
NEUROLOGICAL EVALUATION:
Sensory Deficit Testing:
The following sensory information was obtained utilizing a pinwheel.
There was hypoesthesia, which frequently interferes with activity, noted in the sensory distribution of the median nerve branch of the C6 nerve root, which affects sensation to the middle finger, and grip strength. This was also the nerve root noted to be affected on the EMG test results. Please see report for further information.
There was hypoesthesia, which frequently interferes with activity, noted on the left side at the dermatome zone of the C7 Spinal Nerve, which goes across the back at the top of the ribs down the posterior surface of the arm to include the palm and back of the hand, including the middle finger.
There was also hypoesthesia, which may prevent activity, noted on the left side at the dermatome zone of the C8 Spinal Nerve, which goes from just above the armpits across the back and down the inferior surface of the arm to include the palm and back of the hand, including the ring and little finger.
ORTHOPEDIC EVALUATION:
Cervical Lesion Tests:
The Maximum Cervical Compression Test, which is usually indicative of cervical nerve root compression, was positive on the left. In this test, the patient, sitting upright, attempts to laterally flex the neck and head toward the affected shoulder. Then the examiner directs the patient to bring the chin as close as possible to the shoulder. The test may be repeated passively if there is no response when the patient does the action actively. The test is positive when the action causes radicular pain on the side of the flexion and rotation. A positive test reveals cervical nerve root compression in that the action narrows the diameters of the intervertebral foramina as much as anatomically possible.
PALPATION EVALUATION:
Palpation, which is an examination using the hands, was performed to evaluate Mr. Top's response to pressure and to examine tissue consistency.
Palpation of the left upper thoracic group of the dorsum disclosed severe pain, muscle spasms, and myofascitis in the scapula. Spasm of the left paracervical and trapezius muscle groups was also noted. Significantly, palpating the trigger point in the left rhomboid replicated the chest pain which caused the patient to seek medical evaluation of his heart and lungs.
MEDICAL EVALUATIONS:
On October 2, 2000, Mr. Top was seen by Dr. Fred Smith, a medical physiatrist. Dr. Smith examined this patient, and his impressions were:
1. Radicular Neck Pain compatible with a Cervical Radiculopathy (See EMG Findings)
2. Left Shoulder and upper arm pain, secondary to contusion injury
3. Low Back Pain with a Myofascial Component
4. Post-Concussive Type Headaches, aggravated by his neck pain.
EMG STUDY:
On November 17, 2000, Dr. Smith performed an EMG study on his upper extremities. The results indicated a "Left C6 Radiculopathy." Please see enclosed report for additional information.
X-RAY STUDIES:
Date of Study: July 20, 2000
The following films were available for review:
Cervical Spine:
Anterior-Posterior
Lateral
Additional X-Ray Information:
The lateral film revealed a loss of the normal lordotic curve, indicating that there has been damage to the ligamentous structures, which is also a typical sequela of cervical acceleration/deceleration (CAD) injuries.
A CT scan was immediately ordered of the patient's cervical spine to rule out occult fracture. This scan was negative for fracture.
DIAGNOSIS:
Cervical Acceleration/Deceleration Syndrome with resultant
Cervical Radiculopathy
Thoracic Sprain/Strain with resultant Myofascial Trigger Points
IMPAIRMENT RATING:
Cervical Spine injury with residuals: 4% Whole-Person
(Category II, Table 15-7)
Cervical Range of Motion:
Degrees of Motion Impairment Percentage
Flexion: 45 degrees 1% of the Whole-Person
Extension: 40 degrees 2% of the Whole-Person
Right Lateral Flexion: 35 degrees 1% of the Whole-Person
Left Rotation: 65 degrees 1% of the Whole-Person
Right Rotation: 60 degrees 1% of the Whole-Person
Combined Cervical Whole-Person Range of Motion Impairment: 6%
Total Combined Whole-Person Spinal Impairment: 10%
Upper Extremity Impairments:
(Note: All conversions from Upper Extremity values to Whole-Person values are based on the conversion chart (Table 3), on page 20 of the A.M.A. Guides.)
Upper Extremity Sensory Impairment:
When rating the sensory loss of the left upper extremity, I chose to rate the ulnar and median nerves, which include innervation from the C6, 7, and C8 spinal nerve roots. The resulting sensory loss overlap, is more accurately rated by the sensory cutaneous innervations.
Median Nerve: 5% Maximum Upper Extremity Impairment (radial palmar digital of middle finger)
Sensory Grade 4 (61%-80% Sensory Deficit): Hypoesthesia, on the left side, which may prevent activity.
Impairment: 5% X 80% = 4% of the Upper Extremity
Ulnar Nerve: Ulnar Palmar Digital of ring finger: 2% Maximum Upper Extremity Impairment
Sensory Grade 4 (61%-80% Sensory Deficit): Hypoesthesia, on the left side, which may prevent activity.
Impairment: 2% X 80% = 1.6% of the Upper Extremity
Ulnar Nerve: Ulnar palmar digital of little finger: 3% Maximum Upper Extremity
Sensory Grade 4 (61%-80% Sensory Deficit): Hypoesthesia, on the left side, which may prevent activity.
Impairment: 3% X 80% = 2.4% Upper Extremity
Combined Upper Extremity Sensory Impairment: 8%
Grip Strength Impairment:
Left Hand: 15, 17, 18 Avg: 16.7 kilograms.
Right Hand: 35, 40, 37 Avg: 37.3 kilograms.
Utilizing the A.M.A. Guides' 'Strength Loss Index' Formula from page 65 of the Guides:
Left Hand: (37.3 - 16.67) divided by 37.3 = 55.% Strength Loss Index.
55% Strength Loss Index = 20% Impairment of the Left Upper Extremity
Total Combined Upper Extremity Impairment (20 C 8): 26% U.E.
Conversion to Whole-Person: 16% WP
Total Combined Permanent Impairment (16 C 10): 24% of the Whole-Person
(All above combinations are based on the A.M.A. Guides’ Combined Values Chart on pages 322 through 324 of the Guides).
TREATMENT:
Treatment for this patient includes: specific spinal manipulation to reduce pressure on nerves and interrosseous disrelationships. Adjunctive therapies to promote flexibility, decrease pain and muscle spasm preparatory to spinal manipulation included: moist heat, and electrical muscle stimulation. Exercises to promote flexibility and to strengthen musculature were recommended.
PROGNOSIS:
The prognosis is poor for this patient to make a complete recovery. In the sixteen (16) months since his last visit with me on July 18, 2002, Mr. Top's complaints have worsened. He continues to suffer recurrent exacerbations and pain, and requires continued chiropractic care.
It continues to be my opinion that this patient's condition is directly, and causally related to the auto crash on July 19, 2000. In all probability, as a direct result of the traumatic injury sustained in the July 19, 2000 motor vehicle crash, there were extremes of joint movement resulting in stretching and tearing of the soft tissues of the cervical and thoracic spine. Injuries of this type are frequently precursors of chronic cervico-dorsal sprain, chronic myositis, and traumatic arthritis. There continues to be chronic re-exacerbations of the patient's symptoms as well as limitations in the patient's ability to do his job and normal daily activities.
This patient, in my opinion, will continue to have episodes of pain, joint tenderness and has a permanent, residual limitation of range of motion in his cervical spine, along with, a permanent sensory loss in his left hand.
RECOMMENDATIONS:
It is my opinion at this time that there is no reason to expect a major change in the patient's clinical picture in the immediate future. It is my recommendation that this patient return to my office for supportive and therapeutic care on a schedule of three times per week for four weeks, in order to reduce the current symptomatic exacerbation, to be reduced as progress is achieved. I have advised the patient that his injuries may continue to interfere with his job and daily activities. I am also recommending that Mr. Top return to Dr. Smith for follow up evaluation, and possibly for a cervical MRI to rule out a cervical disc herniation.
DOCTOR OPINION:
My assessment of this patient's condition, based on chiropractic and medical examinations, radiographic and CT studies, EMG studies, and other objective tests as well as subjective complaints, established these findings to be consistent with the mechanism of injury and type of trauma sustained by this patient as a result of the motor vehicle injury of July 19, 2000. In addition, Mr. Top has suffered a permanent injury to his cervical spine, which continues to interfere with his job and daily activities. Significantly impacting his normal daily activities, as well as his normal sleep, this injury has left Mr. Top with frequent pain and left hand numbness, which at this point is permanent.
Mr. Top has sustained a 24% Whole Person Impairment as defined by the AMA Guides to Permanent Impairment.
Please let me know if you have any questions regarding Mr. Top's injuries, related treatment, or my permanency determination.
Certification Statement:
I certify that the statements contained in the foregoing report are true. I understand that it is perjury to make willfully false statements, and I may be subject to prosecution.
Very truly yours,
Dr. James W. Campbell
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