APPORTIONMENT:

Labor Code 4663 : There is radiographic evidence of pre-existing degenerative disc disease and degenerative joint disease (spondylosis) in the lumber region. especially at the L5/S1 region where over a 75% loss of disc height loss (discopathy) is noted.

Therefore, in the spirit of SB 899, there is reasonable medical probability that the pre-existing degenerative joint disease and degenerative disc disease has predisposed this patient to a portion of her current permanent impairment. More explicitly, it is my medical opinion that 20% of the patient’s permanent impairment is attached to the industrial injury of 03-18-05 and 80% is attached to the pre-existing degenerative joint disease and degenerative joint disease. Aside from the forthcoming, the mechanism of injury (twisting at the waist) does not support attaching the bulk of this impairment to said industrial injury.

Labor Code 4664 : Given the recent ruling concerning over-lapping permanent impairments / disabilities (Strong vs. City and County of San Francisco (2005) WCAB No. SFO 0479038), the discovery that this patient was awarded a significant permanent disability (with future medical care that was sold-off), would invoke § 4664. Further assessment of this region of apportionment is beyond the scope of the QME and is now passed to the insurer for further investigation. I would be happy to comment further if need be.

SUPPORT OF APPORTIONMENT OPINION:

In attempts to create a report that constitutes “substantial medical evidence,” I shall support my opinion on apportionment by presenting evidence based, peer-review medical investigations, which is my right and duty per Title 8 CCR §10606(n) and the recent WCAB en banc decision of Escobedo vs. CNA (2005) 70 CCC 604, which states (among other things) "...a medical report is not substantial evidence unless it sets forth the reasoning behind the physician’s opinion, not merely his or her conclusions."

Degenerative Disc Disease (DDD):

Although it is common knowledge that DDD and DJD are found in the majority of pain-free middle age folks and is not always indicative of future pain or disability, (201,202) the presents of discopathy (thinned disc space) is association with DDD and is indeed predictive of patient pain and suffering as this phenomenon is NOT frequently seen in pain-free people.

More explicitly, in 1976 Torgerson and Dotter published one of the only prospective investigations comparing the radiographic findings of 387 symptomatic spine pain patients with 217 asymptomatic pain-free people (who just happened to have their spines x-rayed for other purposes). The results indicated that disc height loss (as visualized on the lateral radiograph) was much more frequently seen in the symptomatic group of patients when compared to the asymptomatic group people. The authors of this investigation concluded that the radiographic presents of “degenerative disc disease [via disc height loss] is a major cause of… pain.” (200)

Therefore, I feel confident that the aforementioned condition has predisposed this patient to at least a portion of their current level of impairment.

(200) Torgerson WR, Dotter WE. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg 1976;58A:850-853.

(201) Boos N, Rieder R, et al. '95 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations.'Spine. 1995 Dec 15;20(24):2613-25

(202) Elfering A, Boos N, et al. 'A 5-Year Prospective MRI Study in Asymptomatic Individuals'SPINE 2002;27(2):125-134.