In re Claim of Fahrion, 100720 COWC, 5-094-870

Docket Nº:W.C. 5-094-870
Case Date:October 07, 2020
W.C. No. 5-094-870
Colorado Workers Compensation
Industrial Claim Appeals Office
October 7, 2020
          CRANE & TEJADA PC, Attn: BETHIAH BEALE ESQ, (For Claimant)           HALL & EVANS LLC, Attn: DOUGLAS J KOTAREK ESQ, C/O: PAUL R POPOVIC ESQ, (For Respondents)          FINAL ORDER          Respondents seek review of an order of Administrative Law Judge Mottram (ALJ) dated April 20, 2020, that determined claimant had proven that a surgery recommended by Dr. Youssef was reasonable and necessary medical treatment and awarded temporary total disability (TTD) benefits to the claimant We affirm the decision of the ALJ.          Claimant sustained an admitted injury on December 6, 2018, when she slipped and fell in the parking lot at work. She fell on her right side, striking her right shoulder and right hip, snapping her neck, and hitting her head on concrete.          Prior to this injury, claimant had a slip and fall in May 2018 while hiking. Claimant was treated for this incident by Dr. Rosenbaugh, a chiropractor. Claimant injured her right shoulder at that time. Claimant testified that the hiking incident led to pain radiating down her hand to her little finger.          Claimant also sought chiropractic treatment with Dr. Rosenbaugh on October 31, 2018. The chiropractor noted restricted motion “in the left C1 . . . and “bilateral C7.” The chiropractor recommended physical therapy (PT).          The physical therapist noted complaints of increased pain and discomfort through the right shoulder. Claimant did not remember a mechanism of injury, but reported increased pain.          Dr. McLaughlin first evaluated the claimant on November 16, 2018. He noted complaints of right sided cervical pain and right shoulder pain. The cervical pain radiated into her trapezius and down to the lateral arm. The claimant complained of numbness and tingling in the 4th and 5th digits of her right hand. Bowling worsened her symptoms in the upper extremity and neck. Lumbar spine symptoms were also reported from sitting at her desk for periods of time. Dr. McLaughlin performed a diagnostic and therapeutic subacromial injection to the right shoulder.          Claimant attended a previously scheduled PT appointment on December 7, 2018. She reported she slipped on ice the day before and had increased pain on her right side through her back and shoulder.          Dr. McLaughlin again evaluated the claimant on December 12, 2018. Claimant reported worsening right sided cervical pain, upper right extremity numbness, and right shoulder pain. She also reported a new right sided lumbosacral pain. Dr. McLaughlin noted imaging studies of the cervical spine from November 26, 2018, prior to claimant’s fall. Claimant complained of tenderness with palpation of the SI joint with a bruise over her lateral hip. The doctor diagnosed an exacerbation of her cervical pain and right shoulder and arm pain with a new lumbar strain, SI joint strain and trochanteric bursitis. Dr. McLaughlin noted that claimant reported that prior to her fall, she had significantly improved after a shoulder injection, but continued to experience deep achiness in the right arm.          Claimant returned to Dr. McLaughlin on January 24, 2019. Claimant complained of worsening right sided cervical pain. The doctor recommended a right C7-T1 epidural steroid injection (ESI) and such was performed on January 31, 2019.          On April 26, 2019, claimant returned to Dr. McLaughlin and reported that the November shoulder injection had provided significant improvement up until her fall on ice. The January ESI gave good relief for the first day but was not sustained and her symptoms gradually returned. Claimant continued to complain of shoulder pain and right upper extremity weakness, both of which were improved with PT. The MRI and x-rays from November 26, 2018, were reviewed. Claimant had a positive Sperling’s maneuver on the right that radiated into the trapezius and down the arm. Dermatomal testing showed decreased sensation to light touch over C5-6 and C8. Dr. McLaughlin recommended a repeat ESI in the cervical spine and referred claimant for an electrodiagnostic study. The ESI was performed on May 23, 2019.          Claimant underwent electromyography (EMG) of the right upper extremity on June 4, 2019. The EMG showed evidence of insertional activity in a C5 and C6 distribution, suggesting nerve root irritation, but without frank denervation.          Claimant returned to Dr. McLaughlin on June 12, 2019. The doctor noted claimant’s report of temporary relief of 50% of her symptoms following the ESI. Surgical options were discussed but claimant elected to hold off on surgery at that time.          Dr. Jernigan evaluated the claimant on June 26, 2019. He noted claimant’s course of care with Dr. McLaughlin. Dr. Jernigan diagnosed a sprain of ligaments in the cervical spine with right arm radiculopathy and right shoulder contusion and strain. Dr. Jernigan opined that Dr. McLaughlin’s care was appropriate and was causally related to claimant’s work. Claimant returned to Dr. Jernigan on July 19, 2019, and was referred for an MRI of her cervical spine. The MRI was performed on August 5, 2019 and revealed moderate degenerative disc disease, spondylosis and asymmetric uncovertebral joint degenerative changes, left greater than right at C5-6 producing mild spinal canal and moderate left-sided neuroforaminal stenosis. The MRI also showed central broad based C4-5 osteophyte disc complex producing mild deformity of the ventral aspect of the thecal sac, but no significant stenosis that would be new compared...

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