12-0003. BERNARD L. WAGNER Employee v. ANCHORAGE SCHOOL DISTRICT Self-Insured Employer Defendant.

• Court: Alaska

Alaska Workers Compensation Decisions 2012. Workers' Compensation Board 12-0003. BERNARD L. WAGNER Employee v. ANCHORAGE SCHOOL DISTRICT Self-Insured Employer Defendant Alaska Workers' Compensation Appeals Commission BERNARD L. WAGNER, Employee, Applicant, v. ANCHORAGE SCHOOL DISTRICT, Self-Insured Employer, Defendant.AWCBDecision No. 12-0003Filed with AWCB Anchorage, Alaskaon January 6, 2012AWCB Case No. 200701423FINAL DECISION AND ORDERBernard Wagner's (Employee) claim for medical benefits was heard on December 5, 2011. Chancy Croft represented Employee. David Floerchinger represented Anchorage School District (Employer). The record closed on December 7, 2011. ISSUE Employee contends he is entitled to future medical treatment for his neck, shoulders, back, and mental conditions resulting from a January 22, 2007 work injury. Employer contends Employee's shoulder and back conditions are unrelated to the work injury and Employee's neck and mental conditions consisted of temporary aggravations of preexisting conditions, which have resolved. Employee and Employer agree Employer has paid for Employee's work-related medical treatment to date and the parties' dispute involves only future medical care. Is Employee entitled to future medical treatment for his shoulders, neck, back and mental conditions? FINDINGS OF FACT A review of the entire record and the parties' stipulation establishes the following facts by a preponderance of the evidence: 1) On September 5, 1996, Employee underwent a cervical spine magnetic resonance imaging (MRI), and the impression was no disk herniations. There was mild disk bulging at both C5-6 and C6-7 with foraminal spurring on the left side at C5-6 and bilaterally, greater on the left, at C6-7. (Stipulation of Facts at 1, December 5, 2011). 2) On January 24, 2004, Employee was injured while cross-country skiing. Stacy Young, D.C., treated Employee on or around January 28, 2004, for a sprain/strain of the cervical and thoracic spine. Id. 3) January 28, 2004 through March 25, 2004, Dr. Young treated Employee at Healthwise Care Center and Physical Therapy for his skiing injury. The assessment was cerviothoracic and right shoulder sprain/strain injury. Dr. Young stated, "He suffers from posterior and inferior right shoulder capsule tightness and weakness." Id. 4) On February 4, 2004, Employee reported to Dr. Young a stressful work environment. Dr. Young wrote a letter to Employee's employer, United States Postal Service (USPS), excusing Employee from work from January 28, 2004 through February 3, 2004, due to cervical and thoracic sprain/strain. Id. 5) On February 10, 2004 and February 12, 2004, Employee reported to Dr. Young he felt stress from work aggravated his back. Id. at 2. 6) On February 20, 2004, Dr. Young wrote a letter to USPS, excusing Employee from work that day due to spasm in the right trapezius, levator scapulae and rhomboid musculature. Dr. Young also noted Employee reported work was stressful. Id. 7) On February 23, 2004, Dr. Young treated Employee. Employee reported less tightness, as well as his right shoulder felt good. Id. 8) On February 25, 2004, Employee explained to Dr. Young why Employee dropped off a Medical Status Report Form and Family and Medical Leave Act (FMLA) Form. Employee also reported "difficult communication" with his supervisor, and stated he had been released from work temporarily to seek evaluation from a psychologist. Id. 9) On March 9, 2004, Employee continued to report his continued tightness is primarily stress related, but treatment was helpful. Id. 10) On March 18, 2004, Dr. Young signed the FMLA form left by Employee. She stated Employee continued to be treated two times a week, Employee reported the mental stress caused him to become tight and uncomfortable in his neck and upper back and occasionally in his low back, and the treatments helped relieve stress. Dr. Young anticipated three to five more weeks of treatment. Id. 11) On March 25, 2004, Employee reported to Dr. Young he felt he was recovered almost completely from his skiing injuries. He reported he continued to feel discomfort in his neck and upper back due to stress but stated it was related to his situation at work. Id. 12) On October 15, 2004, Patricia Skala, D.O., treated Employee and noted back pain and intermittent migraines. She also noted a plan to refer Employee to Jim Halfpenny. Id. 13) On October 19, 2004, James Halfpenny, PT, evaluated Employee. Mr. Halfpenny noted Employee was unable to work, secondary to dysfunction, Employee reported increased work stress about four months ago with the onset of mid-back pain, and Employee recently tested for a new job, driving a bus for the Anchorage School District (ASD) with onset of pain again. Mr. Halfpenny recommended Employee attend rehabilitative therapy twice weekly for four weeks. Id. 14) On October 29, 2004, Dr. Skala treated Employee for cervical and thoracic back pain, migraines, as well as chronic nausea. Dr. Skala noted a flat affect. Id. 15) Mr. Halfpenny treated Employee twice before Employee was discharged. Employee reported feeling better on November 24, 2004, stating he had started working for ASD driving a bus. Id. 16) On May 25, 2005, Dr. Skala treated Employee and assessed Migraine Cephalgia. Id. at 3. 17) On June 1, 2005, Dr. Skala noted an improvement of Employee's headaches as well as arthritis symptoms in his hands. X-rays were ordered for neck pain. Id. 18) On June 3, 2005, Employee underwent a cervical spine series of x-rays. The impression was degenerative disc disease with spur formation at C5-C6 primarily, which was less prominent at C6-C7, and some onset of spurring at C4 was noted as well. Id. 19) On June 20, 2005, Dr. Skala saw Employee for a follow up of the x-rays. He assessed neck pain with radiculopathy. An MRI was ordered. Id. 20) On June 22, 2005, Employee had an MRI of the cervical spine. The impression was of a mild spinal stenosis secondary to posterior spondylosis accompanied by a very small central disc protrusion at C5-6 and a mild annular degeneration at C6-7. No significant foraminal stenosis was identified. Id. 21) On August 2, 2005, Dr. Louis Kralick evaluated Employee and noted Employee retired from the postal service about a year ago, and was currently employed as a bus driver for tourist trips during the summer and for the school district the rest of the year. Dr. Kralick did not feel it likely Employee was going to improve with continued conservative management, due to the degree of stenosis. Dr. Kralick recommended operative intervention, which would consist of a two level disc excision osteophyte removal and spinal canal decompression with instrumented fusion at C5-6 and C6-7. Id. 22) On August 25, 2005, Employee underwent a pre-operative cervical spine x-ray series. The impression was significant degenerative cervical disc changes at C5-6 and C6-7. Id. 23) On August 26, 2005, Dr. Thomas Dietrich treated Employee and diagnosed moderately severe degenerative cervical disc disease at C5-6 and C6-7, clinical indications of cervical spinal cord involvement and depression. Dr. Dietrich did not attribute any of his diagnoses to any work incident or injury. Dr. Dietrich opined Employee was not medically stable, nor capable of returning to his work as a school bus driver until Employee had better motility of his neck. Id. 24) On August 29, 2005, Dr. Kralick performed an anterior diskectomy and interbody fusion on instrumentation C5, C6 and C7, at Alaska Regional Hospital. Employee was discharged on September 2, 2005. Id. 25) On October 10, 2005, Employee had an x-ray series of the cervical spine. The impression was a stable postoperative grafted and instrumented anterior two level cervical fusion. Id. 26) On January 22, 2007, Employee was assaulted by a high school student in a high school parking lot. Employee was reportedly punched, and kicked in the head and neck, face and ear. He was seen at Alaska Regional Hospital Emergency Room complaining of neck, head and ear pain. The diagnoses given were: 1) facial contusion, and 2) closed head injury. Employee did not believe he lost consciousness but did feel a crunch in the back of his head and complained of neck pain. He did not believe he was kicked in the chest or abdomen. Id. at 4. 27) On January 22, 2007, Employee had a CT scan of his head; the impression was negative. Employee also had a CT scan of his cervical spine; the impression was no evidence of acute fracture or malalignment. Post-operative changes of anterior fusion C5-C7 were noted, as well as severe degenerative changes posterior facets as described, multiple levels. A CT scan of Employee's face was also taken; no facial fracture was identified. Minimal right anterior ethmoid chronic sinusitis was noted. Id. 28) On January 24, 2007, Dr. Skala treated Employee, prescribed medication for pain and inflammation, and restricted Employee from work through Monday. However, on the physician's report of the same date, Dr. Skala wrote Employee was not released and it was unknown for how long. Id. 29) On January 29, 2007, Employee was seen in the Alaska Regional Emergency Room for ongoing pain along the left occiput to the front, and in his left AC area. Employee also reported pain in his right hip area where he was kicked, and thought he had some sciatica from that. Another CT scan of the head was taken to eliminate possibility of intracranial hemorrhage, which was found to be negative...