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Medicolegal Consultations


BILLING POLICY

This is my revised billing policy for legal consultation.

IMAGING: Imaging is vital to my assessment of most cases, and I am able to access many studies on-line. For almost any study in Rhode Island, and any Shields study in Massachusetts, I will obtain them myself at no additional charge with authorization from the patient to do so. Images will be analyzed, selected, and inserted into the reports as appropriate. Any films or CDs sent with records will be returned immediately after review.

I can currently access imaging from the following networks. Given HIPAA constraints, I will need permission (via e-mail is fine) from either you, the claimant, or the claimant’s attorney to do so. Please note that we do IMEs both in MA and RI.

Bristol Radiology (Rhode Island) LifeSpan  
Partners (MGH, BWH) CharterCARE (both Fatima and Roger Williams)  
The Imaging Institute Landmark Hospital Memorial Hospital
Open MRI of New England Rhode Island Medical Imaging Shields MRI
Sturdy Memorial Hospital Toll Gate Radiology XRA Medical Imaging
Norwood Hospital    

INDEPENDENT MEDICAL EXAMINATION (IME): This is charged at a flat rate of $890.00. This amount includes all transcription costs, imaging review, and communication with pertinent lawyers or other consultants. As a courtesy, I will review limited medical records that arrive on or before the day of the IME. "Limited" is defined as less than 100 pages of medical records (including cover letter, dividers, etc.) and less than 4 imaging studies.

If additional records or imaging studies arrive after the day of the IME, they will be reviewed, and the report amended, at a rate of $750 per hour.

COURT APPEARANCE: My charge for a court or arbitration appearance is for either a half-day or a full day. The half-day charge is $5,000 and the full day charge is $7,500. In the event of the need for travel, relevant costs (airline ticket, food, etc.) will be billed in addition. Please note that the above fees include pre-trial meetings on the day of my courtroom appearance.

A "half-day" is defined as my being able to leave court and reasonably arrive either at my office or the hospital by 1pm. If I am unable to do so, an additional $2,500 will be billed.

We will not assign time for a court appearance until we have received a retainer for $2,500 for half day or $5000 for full day.


My preference is to appear at trial instead of undergoing an audiovisual deposition. I have arranged my schedule such that I am available on most Tuesdays and Fridays for courtroom appearances. If an audiovisual deposition has been performed, I would still recommend arranging my appearance at trial. If that occurs, my cost for the audiovisual deposition will be subtracted from the above-mentioned half-day and full-day charges.

DEPOSITION: This is charged at a rate of $900.00 per hour, with a minimum charge of 1 hour. This includes review of any limited additional records and additional imaging studies provided for that meeting (see definition of "limited" above).

RECORD REVIEW: The majority of my consultations involve record reviews, and the rates are as below. It is entirely based on the number of pages.

<100 pages with IME gratis
<250 pages $1,200
250-500 pages $1,800
500-1000 pages $2,000
1000-2000 pages $2,500
2000-3000 pages $3,000
3000-4000 pages $3,500

The report will almost always arrive via e-mail within 10 business days of receipt. Please bear in mind that my clinical responsibilities are foremost, and if patient care needs require more of my time, it may take a few days longer. As always, if you have deadlines such as an arbitration or statute of limitations, please let us know and we will be able to accommodate you. The report will be fully annotated and referenced, and any pertinent imaging will be pasted into the text of the document. The rate above includes review of an unlimited number of imaging CDs, and a 30-minute teleconference if desired. Teleconferences will be scheduled to avoid the painful process of phone tag.

For an urgent review, an additional charge of 25% will be added. "Urgent" is defined as a completed review within 5 business days of my receipt of the records.

DESTRUCTION OF DOCUMENTS: I am often not informed when cases are dismissed or settled. If I have not received correspondence regarding a case for 3 years after the time I have submitted my report, I will destroy all records pertaining to that case.

FIRST REFERRALS FROM AN ATTORNEY OR FIRM: For a first time referral, a 2 hour retainer will be required on receipt of the documents to be reviewed.


INVOLVEMENT IN CASES

I have reviewed medicolegal cases for over 20 years. I have not refused to give my opinion on a case, and will continue that policy. However, referring adjusters or attorneys should be made aware of certain instances when I will not provide testimony against a physician.

  1. When a doctor who is being sued is a personal friend or someone with whom I work closely.

  2. When a doctor has made a mistake that was outside the standard of care, but the patient was not injured in any significant way as a result. Example: Doctor Jones operates at the wrong level of the lumbar spine during a microdiskectomy. A small opening is made microscopically into the lumbar spinal canal, and then closed. This mistake is later recognized, and a short time thereafter the operation is performed at the correct level. The patient claims chronic back pain afterward. I would not help in such a case as a microscopic canal opening and nerve inspection causes no meaningful long-term damages such as back pain.

  3. When a doctor did not make a mistake, but I am asked to render an opinion in regard to causation only. Example: Doctor Smith sees a patient with non-specific symptoms that, only in retrospect, turned out to be the first indications of a brain tumor. The patient undergoes surgery years later and does poorly. In this instance, I might be asked if the patient would have done better if the diagnosis had been made earlier, and if the operation had been performed sooner. While the answer to that is yes, I would not help in such a case as Doctor Smith had treated the patient within the standard of care.

 

CANCELLATION POLICY

We have been experiencing a large number of last minute cancellations and postponements. Many claimants do not show up for their IME's. While we understand the difficulties involved with your scheduling these, and appreciate your involving us in them, we are booking these 2-3 months in advance. We move operations and clinics to accommodate them.

FEES FOR CANCELLATION:

Cancellation or postponement of a TRIAL OR ARBITRATION with more than 10 business days' notice: $1000 of the retainer fee will be returned. The scheduling attorney/firm has no other financial obligation.

Cancellation or postponement of a TRIAL OR ARBITRATION with 5-10 business days' notice: No portion of the retainer fee will be returned. The scheduling attorney/firm has no other financial obligation.

Cancellation or postponement of a TRIAL OR ARBITRATION with less than 5 business days' notice: No portion of the retainer will be returned. The scheduling attorney/firm is responsible for the remainder of the $5000 half day fee, or the $7500 full day fee.

Cancellation or postponement of a TRIAL OR ARBITRATION with NO prior notice: No portion of the retainer will be returned. The scheduling attorney/firm is responsible for the remainder of the $5000 half day fee, or the $7500 full day fee.


Cancellation or postponement of a DEPOSITION more than 20 business days' notice:
No bill will be submitted. Any retainer will be returned.

Cancellation or postponement of a DEPOSITION with 5-20 business days' notice: A bill for half of the allotted time will be submitted. The scheduling attorney/firm is responsible for that amount.

Cancellation or postponement of a DEPOSITION with less than 5 business days' notice: A bill for ¾ of the allotted time will be submitted. The scheduling attorney/firm is responsible for that amount.

Cancellation or postponement of a DEPOSITION with NO prior notice:
In the event of my arrival for a deposition that has been cancelled or postponed without any notification, a bill for the entire amount will be submitted. The scheduling attorney/firm is responsible for that amount.


Cancellation or postponement of an IME more than 10 business days' notice: In the event of my arrival for an IME that has been cancelled or postponed with more than 10 days of notice, there is no financial obligation.

Cancellation or postponement of an IME with 5-10 business days' notice: A bill for one-quarter of the IME cost will be submitted. The scheduling attorney/firm is responsible for that amount.

Cancellation or postponement of an IME with less than 5 business days' notice: A bill for one-half of the IME will be submitted. The scheduling attorney/firm is responsible for that amount.

Cancellation or postponement of an IME with NO prior notice: In the event of my arrival for an IME that has been cancelled or postponed without any notification, a bill for the entire amount will be submitted. The scheduling attorney/firm is responsible for that amount.

RECORD KEEPING: There has been a remarkable amount of change in the transmission and maintenance of medical records over the past several years. We now receive imaging studies and other records by paper, CD, flash drive, or link to repository, e.g. DropBox. Our current policy is to maintain paper documents for 3-4 years. For example, any case we receive this year will be destroyed in January of 2019. Imaging studies and surveillance video sent to us on CD, DVD, or flash drive, or film will be analyzed, and pertinent images pasted into the medical report. They will then be destroyed unless we are asked to return them.

MEANS OF NOTIFICATION: We check our email several times per day. In addition to calling our office (401 453-3545), please send email notice to the below addresses with a return receipt request:

stephensaris@comcast.net
lucia@neurosurgery-associates.com
donna@neurosurgery-associates.com

PAYMENT FOR SERVICES - In addition, we apologize but we are spending increasing amounts of effort and time collecting fees for our services. If we have not received payment 2 months (60 days) after you receive our report and invoice, we will add a surcharge of 1.5% per month.

We appreciate your understanding and cooperation. A copy of this policy will be faxed or emailed to your office at the time of scheduling.


 

Sample record review performed by Dr. Saris

Case 1: Referred by defense firm in which claimant suffered serious injuries. Pro-plaintiff opinion was rendered.

RECORD REVIEW ON JAMES SMITH

On August 22, 2005, he underwent LS MR. It was compared to 2005 study. There was mild stenosis at L4-L5 and decreased disc space at L3-L4. There was a 3 mm anterolisthesis at L4-L5.

In September 2006, Dr. Emond saw him. He describes a 2004 MRI that showed a small central disc herniation at L5-S1. A detailed lower limb neurological examination was normal.

On September 15, 2006, he underwent a head CT that was normal.

On September 21, 2006, he underwent lumbar electrodiagnostic studies. A chronic right S1 denervation was described.

On May 1, 2008, Dr. White saw him for back problems. An MRI in 2005 revealed stenosis. He had no leg weakness. It was a longstanding problem, and narcotics were to be avoided.

On September 6, 2008, Dr. Green saw him for the back problems. He was retired, but drove a truck part time. His highest level of education was high school.

On February 4, 2009, Dr. Brown saw him. He had undergone L3-L4, L4-L5, and L5-S1 facet injections. His pain level was up to 6/10, and it was worst at night.

On August 30, 2010, he underwent LS MR. It was compared to 2005 study and it showed degenerative changes with stenosis.

On September 22, 2010, Dr. Sanders saw him for back problems. He had increase in his low back pain and leg pain in an L5 distribution. Conservative measures were recommended.

On November 1, 2010, he underwent lumbar epidural steroid injection.

On November 11, 2010, Dr. Sindon saw him in clinic for several problems including low back pain.

On November 16, 2010, he had undergone L4-L5 epidural steroid injections for back problems. His pain was rated as 4/10. He bicycled up to 6 miles per day. Conservative measures were recommended.

On February 28, 2011, he was seen at the for L4-L5 spinal stenosis. Epidural steroids were recommended.

On March, 31, 2011, Dr. Jinson saw him for a number of medical problems including Celebrex-dependent back pain. Facet blocks by Dr. Arton had not been helpful.

On April 6, 2011, Ms. Boykin, a physician's assistant, saw him. He had undergone an L4-L5 epidural steroid injection. He did not have any relief and continued to have pain. He was on Celebrex. He also had 5/10 discomfort. Neurological examination was normal.

On April 8, 2011, he underwent cardiac evaluation. He is 65 years old and weighed 228 pounds. He had paroxysmal atrial fibrillation. He was a truck driver.

On April 8, 2011, Dr. Rosen saw him for a cardiac and back evaluation. Impression was paroxysmal atrial fibrillation.

On May 8, 2011, Mr. Smith claims he was injured seriously at the time of a motor vehicle accident.

On May 10, 2011, Dr. Minson saw him. He had back pain and was using Celebrex. He had the diagnosis of lumbar spinal stenosis. He had undergone an MR in August 2010 that showed spinal stenosis. He had erectile dysfunction for which he was on Cialis. Conservative measures were recommended.

On May 19, 2011, a crash report that was created. While travelling self-bound, another vehicle attempted to change lanes and struck him on his passenger's side.

On May 23, 2011, he filled out a pain diagram. He indicates discomfort across the low back. There was no indication of discomfort down his legs.

On June 9, 2011, Dr. Brown saw him. He had back pain and left sciatica. He had undergone MRI. His neurological examination was normal. His impression was back pain after motor vehicle accident for which conservative measures were warranted.

On June 9, 2011, Dr. Winsome saw him. He had back pain and left sciatica after an MVA. Neurological examination was normal.

On June 14, 2011, he was seen in chiropractic clinic. Impression was a soft tissue injury with nerve inflammation.

Between June 17, 2011 and August 3, 2011, he was seen in chiropractic clinic on many occasions. Dr. Burns felt that his problems are related to the accident.

On June 30, 2011, a neurologist saw him. He describes him as a 65-year-old man who had been in an MVA in May 2011. His vehicle was hit on the passenger's side. He was wearing a seat belt and developed immediate pain radiating involving his back and left leg. He had some leg pain, but it was more on the left. He had a history of back pain with disease at L5-S1. He had undergone epidural steroid injections in the past without relief. Chiropractic manipulation had been somewhat helpful. He was on Celebrex. A detailed neurologic examination was completely normal. Impression was radiculopathy. His MRI showed an active S1 denervation. He had aggravation of his degenerative disease. Also, he may have a new disc protrusion at the L5-S1 level from the accident." He should continue on conservative measures and hold off on an MRI.

On June 30, 2011, Dr. White performed electrodiagnostic studies. There were positive sharp waves in the left medial gastrocnemius and gluteus maximus. There was increased insertional activity in those two muscles. Anterior tibialis muscle recordings were normal suggestive of left S1 denervation.

On July 13, 2011, Dr. Nicley saw him. He had many years of back problems. "He was involved in a minor fender bender on May 19, 2011, and since then, he has had exacerbation of his symptoms. Before, he never had sciatica or radicular pain down his lower extremities, so this is the first time over the past several months that he has had radicular-type pain. Most of his symptoms were down his left lower extremity, but he can have pain into his right buttock. He describes his pain in his left leg as pain below the level of the knee." An L5 cortisone injection was performed.

On July 20, 2011, Dr. Brown saw him. He had undergone epidural injections with improvement. A detailed neurological examination, in particular reflexes, were normal and symmetric.

On July 29, 2011, a form describes back and bilateral leg problems after May 2011 accident. The diagnosis was a soft tissue injury and nerve inflammation.

Between August 20, 2011 and June 11, 2009, Dr. Smith saw him on several occasions for problems ranging from high blood pressure, back pain, esophagitis, memory loss, impaired glucose tolerance, cough, rhinitis, hypercholesterolemia, sinusitis, and history of depression.

On September 2, 2011, Dr. Brown saw him. He had no complaints. His father had Alzheimer's disease. Detailed neurological examination was clearly normal.

On September 20, 2011, Dr. Brown saw him for back and leg pain. A brain MRI and EEG were unremarkable. Detailed neurological examination was normal. "The patient has an L4-L5 disc protrusion to the left irritating the left S1 nerve root giving him a left S1 radiculopathy." Conservative measures were recommended.

On October 17, 2011, Dr. Lison saw him. He was described as a 65-year-old man for an evaluation of back and bilateral leg pain, worse in the left leg. He had bilateral weakness in his thighs. Neurological examination was normal. A September 2011 MR showed desiccation at L2-L3, L3-L4, L4-L5, and L5-S1. There was a large left-sided disc herniation at L4-L5. This was compared to 2010 MR, which showed degenerative changes without herniation. X-rays showed a grade I L4-L5 listhesis. Surgery was recommended at L4-L5, but this would not solve all of his problems.

On November 10, 2011, he underwent surgery. The preoperative diagnosis was degenerative listhesis at L4-L5 and a herniation at L4-L5 on the left. There was a large synovial cyst at L4-L5 on the right. There is a small disc herniation at L4-L5 on the left that was identified and removed.

On September 7, 2011, Dr. Brown saw him. His preoperative pain had resolved. X-rays showed satisfactory position of the L4-L5 instrumentation.

On September 11, 2012, a photograph of a vehicle is shown. There was no visible damage. It notes that the light had been displaced. A picture of the driver's side of the vehicle shows very minor damage with denting of the left front fender.

ASSESSMENT: I have made the below statements to a reasonable degree of medical certainty.

Mr. James Smith is a middle-aged man who claims he was injured seriously over a year ago after a motor vehicle accident. I have been asked to comment on the injuries he suffered after this MVA, appropriateness of his treatment for it, and his current medical condition.

His records support a significant, structural injury to his lumbosacral spine after this accident. The records are clear that he had years of back problems prior to this event, and had been seeing healthcare providers days beforehand due to it. However, the appearance of new left leg pain in association with electrical abnormalities and a disc extrusion on MR support a new injury superimposed on his chronic ones. He underwent the appropriate treatment for it, which was removal of the disc fragment and a segmental fixation.

The basis for my opinion is that he has numerous imaging studies and evaluations that support chronic back pain. In general, this manner of problem will cause predominately axial back pain that usually gets worse on exertion. An extruded disc with nerve compression will cause pain radiating down one leg. In the case of Mr. Smith, he developed such new pain predominantly in his left leg. His post-injury MR also shows a several millimeter listhesis with a new disk extrusion. In addition to that, Dr. Brown's electrical studies show active denervation in his left leg. Taken in aggregate, this supports the diagnosis of a new structural spine abnormality caused by the accident.

He has since undergone surgery, as mentioned above. I have not been provided with recent notes that describe his current medical condition. I need the notes both of his internist, Dr. Smith, and his spine surgeon Dr. Jones within the past three months. That will better enable me to assess his current medical condition, and whether his surgery was successful.

To assess his current medical condition, as mentioned above, I will need to see all clinic notes within the past three months that pertain to his pain. Furthermore, we need to perform an independent medical evaluation if he continues to complain of pain or the problems that he relates to the 2011 accident.

Signed under the pains and penalties of perjury.



Stephen Saris, M.D.



Case 2: Case referred by defense firm regarding a man who claimed spinal injuries after an MVA. Unfavorable review on behalf of the plaintiff. All names and locations changed.

RECORD REVIEW ON MARK SMITH

On September 13, 2004, he was seen in the Emergency Room. He had slipped and injured his back. On the pain diagram, he indicated discomfort centrally in the low back. Neurological examination was normal. Neurological examination was normal. He was felt to have a soft tissue back injury. Lumbosacral x-rays were unremarkable.

On September 17, 2004, he underwent an LS CT. No abnormalities were noted.

On May 5, 2007, he had back pain. Neurological examination was normal. On the pain diagram, he indicated discomfort in the low back centrally. The diagnosis was a soft tissue back injury.

On May 8, 2007, he underwent an LS MR. It showed tiny central L4-L5 and L5-S1 disk protrusions.

On June 4, 2007, he was seen at Physical Therapy. He had back pain due to a soft tissue injury.

On July 3, 2008, Mr. Smith claims he was injured seriously after a motor vehicle accident (MVA, subject accident).

On July 3, 2008, a crash description was created. A photograph of the accident scene shows a Honda and a truck with a trailer hitch. The front of the Honda has collided with the driver's side of the truck. Photographs show significant damage to the front of the Honda with crumpling of the hood.

On July 3, 2008, he was seen. Neurological examination was normal. There was no pain on palpation of the dorsal neck. On the pain diagram, he indicated discomfort in the small of his neck. His diagnosis was a nasal fracture.

On July 23, 2008, Dr. Jones, an ear, nose, and throat surgeon, saw him. His conclusion was that there did not appear to be functional or cosmetic deficit from his injury.

On September 5, 2008, Dr. Sindal saw him for an initial clinical consultation. He describes him as a 23-year-old man who worked at Dunkin' Donuts. Initially, the pain began when he fell at work years previously. There had been a more recent motor vehicle accident. An MR showed multiple protrusions. He was 5 feet 5 inches and 150 pounds. Neurological examination was normal. He has felt to have sacroiliac joint pain as well as disk protrusions.

On November 26, 2008, Dr. Sindal performed an SI injection at SMH.

On February 12, 2009, Dr. Sindal saw him for an SI injection.

On April 14, 2009, Dr. Sindal performed L5-S1 epidural steroid injections.

On July 16, 2009, Dr. Sindal saw him. He had undergone two SI injections that were helpful. Neurological examination was normal.. He would continue on his pain medications and x-rays were ordered.

On July 24, 2009, he underwent an LS MR. It showed small central protrusions at L4-L5 and L5-S1. There was no change compared to a May 2007 study1.

On July 27, 2009, he underwent x-rays. He might have right sacroiliitis.

On July 27, 2009, he underwent an LS MR. It was compared to a May 2007 study. There was no significant interval change, and widespread degenerative changes were noted.

On July 29, 2009, he underwent a right sacroiliac injection.

On September 11, 2009, Dr. Sindal saw him. He underwent a sacroiliac joint injection.

On September 16, 2009, Nurse Anson wrote a letter that Mr. Smith was disabled due to his work-related injury.

On August 12, 2010, Dr. Laswon, an orthopedic surgeon, saw him. The subject accident is described. He was single and had no children, and smoked half a pack of cigarettes per day. Neurological examination was normal. The diagnosis was a soft tissue back injury.

On August 18, 2010, he underwent an LS MR. He had a central disk herniation at L4-L5 without compression.

On August 19, 2010, Dr. Laswon saw him. An MR done showed "a central canal extrusion at L4-L5. It does not result in significant central canal narrowing."

On September 7, 2010, Nurse Smith wrote a letter to Mr. Ernst. He had chronic back pain in addition to anxiety and depression. He would benefit from psychological counseling.

On September 9, 2010, Dr. Ranison, a neurosurgeon, saw him. He had pain traveling from the back into both buttocks and down both legs. On examination, he was 5 feet 4 inches and 150 pounds.


Neurological examination was normal. He recommended an EMG. He had undergone a three LS MRs without structural compression. He did not believe that surgery would help.

On February 28, 2011, Dr. Johnson wrote a letter in his regard. Mr. Smith asked him for an increase in Ambien that he refused. He wanted an increase in his Valium that he refused.

On April 13, 2011, he underwent a cervical MR. It was a normal study with a rightward disk-osteophyte complex at T1-T2.

On April 19, 2011, Dr. Johnson spoke with him. He was having worsening pain on decreased doses of Oxycodone. He had taken 120 20 mg Oxycodone tablets in two weeks. He was told that he was being discharged from the practice due to noncompliance with pain contract.

On October 19, 2011, Mr. Smith put forth answers to interrogatories. He claims that the other vehicle rammed a stop sign and collided with him. In answer #5, he claims that about five years previously he fell at work and injured his back. He treated for under a month with physical therapy. In answer #10, he states that the weather was sunny and was dry. The front of his vehicle came in contact with the driver's side of the other vehicle. In answer #17, he states that he had several injuries as a result including back pain. He had treated at several facilities. He underwent an MRI. His physicians felt that his back would always cause some level of pain and functionality. He felt he would never regain full range of motion in his back.

On October 19, 2011, Mr. Smith was deposed. He lived with his parents and his brother. He graduated high school, and attended College without completing his degree. He was not currently employed, and had previously worked. He stopped working in September 2009 because of back troubles. He was in another accident on September 6, 2010. On page #16, he states that he returned to work a few days after the accident. On page #18, he states he continued working until September 2009. On page #19, he states that he quit his job and did not look for employment. On page #20, he describes filing a Workers' Compensation claim. On page #21, he describes a work-related injury. He was traveling from a store to the bank to make a deposit. That was the time after the subject accident. On page #26, he describes a back accident about five years previously. He received conservative treatment and recovered fully. On page #30, he describes being treated. On page #34, he describes his ongoing problems. He had "major muscle spasms" across his low back. The frequency was at least two per hour. On page #35, he describes his current medications as oxycodone 20 mg, OxyContin 20 mg, and Soma 350 mg. He had been on the OxyContin for approximately nine months. This was prescribed by Dr. Jamison. On page #36, he states that he had settled his Workers' Compensation claim and is looking for work. It was his ambition to own his own shop some day. On page #42, he describes an MRI in July 2007. His understanding of his MRI showed that everything was fine. On page #46, he describes spinal injections at by Dr. Sindal. Sometimes it helped and sometimes it did not. No one had recommended surgery. On page #47, he states that after the subject accident he had pain radiating down both legs. On page #51, he states that Dr. Johnson had given him clearance to return to work. On page #52, he describes another accident in September 2010 when he was 24. On page #78, he states he believes he was knocked unconscious by the airbag. On page #90, he describes helping his mother with domestic chores such as carrying baskets of laundry. On page #91, he states that his car was damaged beyond repair at the time of the subject accident. Deposition ends on page #94.


 

IMAGING: I reviewed the below imaging studies personally.

On June 3, 2007, he underwent an LS MR at SMH. It is a normal study. There are age-appropriate degenerative changes. There is no nerve entrapment, and no stenosis. At L3-L4, there is a disk bulge. Protrusions and bulges are normal degenerative changes as detailed in the footnote below.

     
L45
L5S1


Figure 1: The above shows the May 2007 study. On the left are T1 and T2 sagittal views of the spine. They show normal alignment and age-appropriate degenerative change, even for someone in their 20s. The images on the right are axial sections through L4-L5 and L5-S1. There is no anatomical abnormality of any kind.

On July 27, 2009, he underwent an LS MR. It is a normal study, and there is no interval change compared to the 2007 study.

_____________________________

2The Diagnostic Accuracy of Magnetic Resonance Imaging. Boos N, Rieder, et al. Spine 20:2613-25, 1995.
Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies. A systematic review. Endean et al. Spine. 2:160-169, 2011.
MRI of the Lumbar Spine in People without Back Pain. Jenson et al. NEJM 331: 69-73, 1994
Abnormal MRI of the Lumbar Spine in Asymptomatic Subjects JBJS 72A: 403-8, 1990


 

     
L45
L5S1

Figure 2: The pictures on the left are T1 and T2 sagittal images of the LS spine. As can be seen in comparison to the pre-injury study, there is no change between the two. The same applies to the axial sections through L4-L5 and L5-S1, respectively.

ASSESSMENT: I have made the below statements to a reasonable degree of medical certainty.

Mr. Mark Smith is a young man who claims he was injured seriously after a motor vehicle accident over three years ago. He had a soft tissue injury that soon healed. He is entirely well from the standpoint of the subject accident at this time, and was entirely well years ago.

Mr. Smith had what is termed in medicine a soft tissue injury. This involves twisting or stretching of the supporting structures of the musculoskeletal system. Examples of these are the muscles and ligaments. Similar to an ankle sprain, these are very painful in the short term, and heal in a very brief period of time. The standard time for healing is days to weeks, though they can last for a few months. For that reason, by November 2008, he had arrived at a medical end result. According to the 6th version of the American Medical Association guidelines (see calculation below). He had 0% whole person impairment. He similarly had no functional impairment or disability. He could have returned to normal activities at that time without restriction. That would include not only physically demanding activities in his personal life, but any form of activity at Dunkin' Donuts including lifting 50 or greater pound objects. He could have done so at what the USDOL defines as very heavy work.

The standards by which patients such as Mr. Smith are evaluated are the neurological examination or imaging studies. There are numerous neurological examinations documented in the highlighted areas above in yellow. None show any pattern of weakness, numbness, or reflex change that would indicate injury to a nerve or the spinal cord. This calls his credibility into question.

3 Pain after whiplash. A prospective controlled inception cohort study. Obelienience D, et al. J Neuro Neurosurgery Psych 66: 279-283, 1999.
Correlation of clinical finding, collision parameters, and psychological factors in the outcome of whiplash associated disorders. J Neurol Neurosurg Psych 75: 758-764, 2004
A prospective cohort study of the outcome of acute whiplash injury in Greece. Clin Exp Rheum 18: 67-70, 2000. M. Partheni.
4UNITED STATES DEPARTMENT OF LABOR, DICTIONARY OF OCCUPATIONAL TITLES, AND JOB CLASSIFICATIONS


HEAVY WORK: The employee make exert 50 to 100 pounds of force occasionally (< 1/3rd of the time), and/or 25 to 50 pounds of force frequently (1/3rd to 2/3rds of the time), and/or 10 to 20 pounds of force constantly (> 2/3rd of the time) to move objects. Physical demand requirements are in excess of those for medium work.


 

We have the unusual advantage of pre-injury and post-injury studies of the part of his body where he feels discomfort. Both are normal. Protrusions are a common feature of spinal degeneration in all patients as they get older, even those in their 20s.2 They are not caused by a single trauma, do not cause pain, and require no treatment. For his claim of narcotic-dependent pain to be credible, one would expect to see a serious and structural injury such as a fracture or extrusion. No such findings are present.

I am critical of his health care providers, particularly Dr. Ledbetter, who has maintained him on high doses of narcotics when there are no verifiable medical abnormalities. He has developed a substance dependency as a consequence. He should be referred to a trained health care provider for weaning and discontinuation from his narcotics.

If any treatments or diagnostic tests have been ordered in relation to the July 2008 accident, they should be canceled. If other records are present such as health care provider notes, imaging studies, deposition testimony, or video surveillance, they should be sent to my office for my review. If he continues to complain of any other problems that he relates to the accident in question, he should be referred to my office for medical evaluation.

Signed under the pains and penalty of perjury.




Stephen Saris, M.D.


 

  Net adjustment
(GMFH-CDX) = NA6
(GMPE-CDX) = 0
(GMCS-CDX) = 0
Net adjustment (sum of above three)= 0
  CDX-GRADE MODIFIER=   0     = Grade modifier C
FINAL WHOLE PERSON IMPAIRMENT= 0%
Functional history7
       
  PDQ Grade modifier Activity level
  0 0 asymptomatic or inconsistent symptoms
  1 0-70 pain, symptoms with strenuous/vigorous activity
  2 71-100 pain, symptom with normal activity
  3 101-130 pain, symptoms with less than normal activity
  4 131-150 pain, symptoms at rest, limited to sedentary activity

 

_____________________________

5Guidelines to the Evaluation of Permanent Impairment, 2008 American Medical Association, Library of Congress
6
"This is 2 or more points higher than the class assignment and therefore discounted." page 584, 6th version AMA Guidelines
7Subjective complaints without objective physical findings or significant clinical abnormalities are generally assigned class 0 and have no ratable impairment. Page 561 and 575, 6th version AMA guidelines


Case 3: Referral from plaintiffs' firm on alleged medical malpractice. Opinion rendered in favor of plaintiff

RECORD REVIEW ON JOHN SMITH

On April 10, 2002, a brain MR showed a pituitary tumor. There was probable right cavernous sinus extension.

On September 6, 2002, Dr. Oland dictated an operative note. When the dura on the anterior sella was incised, there was soft tumor.

On September 6, 2002, at approximately noon, a PACU assessment was performed. On neurological assessment, vision was normal.

On September 7, 2002, his vision is described as blurry in the left eye.

On September 7, 2002, Dr. Kent examined tissue after a pituitary surgery. The diagnosis was a pituitary adenoma. There was no description of necrotic material.

On September 8, 2002, Dr. Geenan consulted on him. On review of systems, it says "negative for visual changes." On examination, he describes "…no double vision, no blurry vision. His pupils were slightly constricted with sluggish reaction to light."

On September 8, 2002, Dr. Andrews consulted on him. She discussed various medical issues. On examination, she describes no double or blurry vision. His pupils were constricted with a sluggish reaction to light.

On September 8, 2002, his level of consciousness was depressed. He was lethargic and answered questions appropriately, but was slow and followed them easily. His pupils were 3 mm.

On September 8, 2002, a nursing note describes marked difficulty with vision.

On September 9, 2002, an MRI showed a large suprasellar mass with blood. It was followed conservatively. He was referred to the University of Nebraska.

On September 10, 2002, Dr. Dintner saw him. Mr. Smith was four days out from pituitary surgery. He had no light perception in either eye; they were 6 mm and non-reactive. He opined a microvascular injury.

On September 10, 2002, a note was placed on the progress section. His visual problems are documented. It states that there was no mass effect on chiasm.

On September 13, 2002, Dr. Antronich saw him. He had declined in vision after surgery, but his MRI showed "typical postoperative changes." Examination showed markedly diminished vision with the ability to identify fingers and track motion. He was unable to identify any significant mass effect. There are no indications for any additional surgery.

On September 27, 2002, Dr. Johnson saw him. He had undergone surgery, and had visual decline afterward. Neurological examination showed a minimally reactive left pupil, and a non-reactive right pupil. He had no vision in his right eye, and could count fingers in the left eye. He had a 6th nerve palsy on the right. A follow-up scan would be obtained.

On September 27, 2002, Dr. Johnson dictated an operative report. In the sella, there was clotted blood and necrotic material. The diaphragm was not visualized, but he felt he obtained a good decompression superiorly. Fat was placed in the sella.

On September 27, 2002, Dr. Sindt reviewed the pathology report. The pituitary specimen was predominantly necrotic tissue. Hormonal screens were non-contributory.

On September 27, 2002, Dr. Johnson described bleeding within the postoperative tumor bed.

On September 29, 2002, Dr. Johnson dictated an operative report.

On September 30, 2002, a discharge summary was dictated. Mr. Smith is described as a man who had undergone surgery. On the second postoperative day, he became confused. CT showed blood in the tumor bed.

On January 8, 2002, he was seen by neuro-ophthalmology.

On January 8, 2002, Dr. Trewnt saw him. He had undergone repeat trans-sphenoidal surgery due to a postoperative hemorrhage. His vision had improved to 20/100 in the left eye. There was nothing that could be done from an ophthalmologic standpoint.

IMAGING:
I reviewed the below imaging studies personally.

On November 26, 2002, he underwent a contrast pituitary MR. It shows a pituitary macroadenoma. It has a typical appearance, and might invade the right cavernous sinus. There is contact and elevation of the optic chiasm.

On September 9, 2007, he underwent another MRI. It shows that he has undergone surgery. There is probable blood product in the resection cavity (orange arrow). There is bowing of the optic chiasm (orange arrow).

On September 28, 2002, he underwent another pituitary MR. There is mass effect from the suprasellar tumor (red arrow). The infundibulum was pushed into the patient's left.

ASSESSMENT: I have made the below statements to a reasonable degree of medical certainty.

Mr. John Smith is a middle-aged man who underwent pituitary surgery. Approximately two days after a seemingly uneventful trans-sphenoidal removal, he lost his vision. The issue I have been asked to address is whether Dr. Oland's decision not to take Mr. Smith back to surgery constituted a deviation from standard medical practice.

It is a standard principle in neurosurgery that when one has performed a surgical procedure, and after that procedure the patient has a possible hemorrhage with significant neurological decline, that such a patient is taken back to surgery. This occurred in the case of Mr. Smith after his surgery. According to the records available to me, he had seemingly normal visual function on June 6 and 7. At some point on June 8, his vision declined to the point where he could not tell whether the lights were on in his room. MR imaging shortly thereafter showed a heterogeneous mass in the sella causing pressure on the optic chiasm. Dr. Oland, felt that the MRI showed a free chiasm and there was no evidence of hemorrhage. Perhaps a vascular insult occurred. High dose steroids were the proper course of action.

The attached image from the post-operative MR clearly shows the compressive (mass) effect that Dr. Oland felt was not present. The standard of care dictated that Mr. Smith be taken urgently back to surgery for decompression. Dr. Johnson did this within hours of his seeing Mr. Smith. While Mr. Smith has had some return of vision, the most current records available to me indicate that it is not useful to the extent that he could return to work or many of the pastimes he enjoyed.

I am aware that perioperative pituitary imaging is difficult to interpret. Often times very worrisome-appearing masses intermixed with the blood can disappear completely leaving an excellent postoperative result. However, in the setting of rapid visual decline, urgent removal of this mass was required. Dr. Johnson's impression at the time of his surgery was that the mass was a mixture of blood and necrotic tumor.

I am similarly aware that even had the patient undergone emergent surgery after his decline, he may have not have recovered any visual function. However, my strong opinion is that early decompression provides the best chance of recovery of vision. Patients who undergo early decompression (in less than a day after diagnosis) will end up with better or normal vision at a higher rate than those who are treated in a delayed manner, or not at all.

If other records are present such as deposition testimony, healthcare provider notes, or imaging studies, they should be sent to me for review.

Signed under the pains and penalty of perjury.




Stephen Saris, M.D.

 

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