June 18, 2007

To Whom It May Concern:

On 05/23/07, I had the pleasure of speaking with Mr. XXXXX (“patient”) for the purpose of causatively assessing his chronic low back pain.  I was also sent a packet of medical reports (1 inch) that in pertinent part contained recent opinions of causation from his VA primary care physician (“PCP”), as well as records dating back to the actual incident of injury of 1963.

HISTORY:

In early July, XXXXX, the patient suffered an injury while he was training with the US Army; he was working as a XXXXXX at the time, but this training was mandatory for all soldiers.  More explicitly, the injury occurred when the patient—who was wearing forty pounds of gear—fell 20 feet off of a “sea wall” and landed in very shallow water on his buttock; he recalls hitting something hard in the water that was probably a rock.  He immediately suffered lower back pain following this incident and subsequently reported to the dispensary for medical treatment and evaluation.

Medical records confirm that on XXXXXX, the patient was indeed evaluated by a medical doctor (his signature is illegible) for this injury.  The SOAP notes from that day describe the stated incident of injury and the occurrence of subsequent low back pain.  Radiographs from that day were negative for fracture, physical therapy was ordered and medication dispensed.

Unfortunately, the patient’s low back pain did not completely abate and became chronic.  In fact, he had another significant flare-up of the original back pain on XXXXX, which required another trip to the Army’s dispensary.  Medical SOAP notes from that day revealed patient was again suffering low back pain.  Examination by a medical doctor (again, the signature of this doctor is illegible) revealed “diffuse swelling” in the lower lumbar spine region.  He was prescribed codeine and Darvocet.

Since the incident, the patient has suffers recurrent low back pain and sciatica. This statement is confirmed by recent medical records from the Honolulu VA.  Particularly germane to this report is a recent medical report from the patient’s primary care physician (“PCP”), Dr. XXXXXXX which was dated XXXXXX.  In this report, the doctor confirms the patient history that I was given and opines, “It is as likely as not that Mr. XXXXX chronic low back pain is related to his injury in the military in XXXX.”

RECENT MEDICAL HISTORY:

On XXXXX, an MRI of the patient’s lumbar spine was ordered by Dr. XXXX.  The pertinent results of that imaging, as interpreted by Dr. XXXXX MD, were as follows: broad-based L4/5 disc bulge that indented the thecal sac, “right greater than left.”  The doctor’s impression was, “mild spondylitic changes in the lumbar spine.  No regions of significant canal compromise are seen.”

On XXXXX EMG/NCS testing was performed by Dr. xxxx MD, which revealed soft-findings (i.e., absent tibial-H reflexes) for bilateral lumbosacral radiculopathy.

Medical records indicate that the patient is on medication (Celebrx and Gabapentin) for his chronic back and leg pains.

DIAGNOSIS:

1) Chronic discogenic lumbar spine pain with bilateral radiculopathy (via positive EMG/NCS testing).

2) Probably L4/5 internal disc disruption.

TREATMENT RECOMMENDATIONS:

It would seem that the patient is in good hands as his current treatment regime (PT, medication, and exercise) if what is recommend by research.  Certainly, a trial course of chiropractic and acupuncture is worth exploring.

If things go downhill, there are several more invasive treatment opinions available, such as SED (http://www.chirogeek.com/002_Yeung_SED.htm); DiscTRODE, and possibly nucleoplasty.  However, provocative discography would be the next step, which would attempt to identify the damaged disc(s).

OPINION ON CAUSATION:

I have been specifically asked to comment on causation of the patient’s current and chronic low back pain.

It is my medical opinion, based upon reasonable medical probability, my familiarity with the medical literature on this subject, and my 20 years of experience in treating back pain that this patient’s chronic low back is the result of a traumatic 20-foot fall, which occurred in early July, 1963 while he was employed with the US Army.

SUPPORT OF OPINION:

It was once touted that 90% of all lower back injuries resolves spontaneously and completely.  However, in the present time, we know better.  In fact, the majority of modern medical investigations into the natural history of low back injury and pain demonstrate that over 50% of the affected people never completely recover.  Moreover, as we shall see, once a lumbar spine is significantly injured, that spine will often forever be susceptible to repeat injury.

Although I can present many research examples to support the foregoing verbiage, since this is military case, let us begin this discussion by reviewing the results of a very well done military investigation into the effects of initial lumbar spine injury:

In 2002, Schneider et al.(1) published an investigation into whether or not a previous back injury was at all predictive of subsequent injury to that same region.  After retrospectively studying the case files of over 1200 U.S. soldiers, the researchers concluded in pertinent part, "The observed risk of [re]injury was seven times greater among previously injured individuals," and, "This suggests that once an individual experiences a musculoskeletal injury to the lower extremity or low back, he may be at increased risk to undergo a similar, subsequent injury." They concluded by saying, "Previous injury history itself may be a powerful predictor of subsequent injury."

So, clearly, once a lumbar spine injured, it becomes vulnerable to subsequent injury, pain, and dysfunction.

In 2003, Hestbaek et al(2) investigated the infamous claim that 90% of all low back pain resolves spontaneously within one month.  After an exhaustive study of all medical research on the natural history of low back pain, the researchers discovered that (1) more that half of patients continued to complain of low back pain one year after its onset and (2) relapse of low back pain occurred twice as frequently in patients with a past history of low back pain than those without.

More explicitly, the researchers found that “the reported proportion of patients who still experienced pain after 12 months was 62% on average,” and “the percentage who experienced relapses of pain was 60%.”

With regard to prevalence of low back pain, the researchers discovered that “in cases with previous episodes [the prevalence] was 56%, which compared with 22% for those with out a prior history of low back pain.  The risk of low back pain was consistently about twice as high for those with the history of low back pain." 

In conclusion, the researchers stated, "The results of the review show that… the overall picture is that low back pain does not resolve itself."

In 2006, Wasiak, et al(3) published the results of an investigation into what factors, if any, were predictive of low back recurrence.  More explicitly, the researchers retrospectively studied the claims of 1,867 previously injured workers.  The strongest predictor of back pain recurrence was having a previous back injury that necessitated a long duration of medical treatment and disability.  More explicitly, the researches stated: “This study identified several risk factors associated with low back pain recurrence in the worker's compensation context.  In particular, the study demonstrated that the duration of the initial episode [of back pain] is strongly related to the likelihood of both medical care and work disability recurrences."

CONCLUSION:

Clearly, the medical literature supports my opinion that the severe axial load injury the patient suffered to his lumbar spine while in the military in XXXX has resulted in life-long chronic low back pain.

If I may be of further assistance, please feel free to contact me.

Sincerely,

Dr. Douglas M. Gillard, DC, BS, QME, IDE

REFERENCES:

#1) Schneider GA, et al. "Evaluating Risk of Re-Injury Among 1214 Army Airborne Soldiers Using a Stratified Survival Model."  Am J Prev Med 2002;18(3S):156–163)

#2) Hestbaek L, et al. "Low back pain: what is the long-term course? A review of studies of general patient populations."  Eur Spine J 2003; 12:149-165  

#3) Wasiak R. et al. “Work disability and costs caused by recurrence of low back pain: longer and more costly than in first episodes.” Spine: 2006 Jan 15;31(2):219-25