To whom it may concern:

The claimant is a stay-at-home mom who sees me today for purposes of Independent Medical Examination with regard to a date of incident from 12/05/2023.  She was unaccompanied during the examination. She brought no assistive devices or braces for during the examination.  She did bring along copies of her MRI studies of her cervical and lumbar spine from 03/06/2024, and MRI studies of her cervical, 2/19/2016 and 06/21/2022.

We obtained photo identification to verify her identity.

I performed an evaluation today of this claimant for the purposes of medical examination only.  The claimant was seen for the purposes of examination regarding the date of the incident noted above. The claimant clearly understood that I was examining her that I was not allowed to provide any kind of therapeutic regimen or prescriptions for care. All the following information and opinions will all be given within a reasonable degree of medical certainty.

She understood the boundaries of the examination.  I explained to her not in the usual physician/claimant relationship, but as an examining physician only.

History:  

The claimant is now 53 years of age and right-handed.  The claimant reports that she was the third car in a chain reaction where she was rear-ended.  She was the seat-belted driver of her car.  She was the last car to be hit.  She did not go to urgent care or emergency facility after the incident.  She went home and then later went to see her chiropractor.  She has had a history of almost ten years of chronic low back and neck complaints and buttock complaints as well, for which she has received multiple treatments by several physicians that will be well-documented in the medical record review.  She had some issues with her back and neck after the motor vehicle injury and received care with the providers as noted.  In the medical records reviewed, Dr. Steven Evans was the primary provider.  She continued with medications for a history of depression and anxiety, and gabapentin. These are medications she has taken for many years.

Present Complaints: 

She reports now, almost two and a half years after the incident, she is feeling much better about the neck region.  She has complaints not in the back, but in the mid buttock region.  She has no back complaints whatsoever in the mid-back or low back or central spine region.  She has no complaints over the greater trochanteric area as well.  She notes her complaints are worse with certain activities.  She continues to do exercises several times a week, and sometimes home Pilates.  She hasn’t been in any formal physical therapy for almost a year and a half.  She continues to take her over-the-counter medications several times a week.  She has not taken any opioids or medical marijuana.  She takes a muscle spasm medication on a rare basis.  She finds that her neck complaints are markedly improved after the motor vehicle injury.  She has no low back complaints, but she does have complaints in her mid-buttock region without any radiation distally.  She reports that after her injection performed 02/11/2025 by Dr. Evans, which sounds like a caudal-type block, her neck symptoms actually improved and she received some improvement in her low back at that time, as well.  She reports no other injuries or accidents since 12/05/2023.

Physical Examination:  

On examination, she has a completely normal neck examination for full range of motion.  She has excellent reflexes.  Her shoulder examination is fully normal for range of motion, stress testing, impingement testing and motor testing.  She has no evidence of any positive neural foraminal compression tests.  I found her neck and shoulder girdle examination was fully normal and benign on complete objective examination.

With reference to her back, she had no tenderness in the low back whatsoever.  She had excellent flexibility.  She showed me several exercises she does at home that involve multiple contortions of her lumbar spine and hip area, none of which cause her any pain or discomfort whatsoever.  When she did a double knee/hip flexion maneuver in supine fashion, she had no complaint in her back or buttock whatsoever.  I could not elicit any buttock complaints during her examination of her hips or SI joint.  I found no evidence of any back dysfunction during her examination.  Her reflexes were +3 and symmetric, and quite brisk.  She had no positive upper motor neuron findings and no clonus or tremor of her lower extremities.  She had no evidence of sciatica in her stretch testing of her sciatic nerve in sitting or supine fashions.  In essence, she had a completely normal objective examination of her neck, shoulders, back, hips and SI joints.

Medical Record Review:  

Medical records were reviewed which include the following:

Extensive medical records were reviewed regarding her prior history of back and neck issues, going back to February 2016.  I reviewed records from Diagnostic Studies from Keystone Spine and Pain Management from 02/09/2016, 05/08/2017, Main Line Health records from 01/19/2018, 07/23/2018, and 06/21/2022.  There were also records from Reading Hospital from 03/06/2024.

There are physician records from 2017 from Keystone Spine and Pain Management, Dr. Steven Evans.  Also, records were noted from an injection procedure performed on 06/05/2017 by Dr. Michael Weaver.  Records were reviewed as well going to 2018 and 2019, from Keystone Spine and Pain Management.  Dr. Ronald Linkow started injection therapies from 11/2019, which were reviewed along with records from Keystone Spine and Pain Management dating to 2022.

This claimant was involved in a rear-end collision as a seat-belted driver on 12/05/2023.  Records post motor vehicle injury (2023) are noted from again, Keystone Spine and Pain Management, including several injection therapies and an operative report from the Surgical Institute of Reading from Dr. William Cano, from 10/08/2024.  Records from Dr. Evans were noted up until 05/12/2025.

Therapy records going back to 2018 were noted, along with chiropractic records noted the day after the incident on 12/06/2023 and until December 2024.

MRI of the cervical spine from February 2016 indicated the claimant had significant arthritic changes in the C5-6 level and also as well in the mid cervical spine.  It was noted at that time that the claimant had neck symptoms of radiation to the left hand.

MRI of the lumbar spine in 2017 referred by Dr. Steven Evans, noted the claimant had bulging disc changes at L4-5 and L5-S1.

MRI of the right shoulder was noted with rotator cuff tendinopathy with a small partial-thickness tear, noted with calcium changes as of January 2018.

MRI cervical spine was performed on 07/23/2018, which noted once again that there was significant degenerative changes at the C4-5 and C5-6 level.  The findings appeared stable compared to prior MRI performed in 2016.  There was some progression of changes compared to the prior study.  Spinal cord, however, appeared normal on evaluation.

Follow up MRI cervical study several years later in 2022 was performed because the claimant had a history of cervical radiculopathy.  Cervical degenerative changes were again noted.  In this study, there is also consideration that the claimant had foraminal changes, moderate on the right side and severe on the left, at the C5-6 level.

MRI lumbar spine performed on 03/06/2024 (several months after the 2023 motor vehicle injury) noted that there was disc bulge at L3-4 and L4-5 degenerative change, but no disc herniation noted.  All the changes noted from the radiologist were atraumatic in nature and degenerative in character.

MRI cervical spine done at the same time, noted once again there were significant changes at the C4-5, C5-6 and C6-7 levels, with arthritic changes seen and bilateral neural foraminal stenosis, similar to what was described several years prior to the motor vehicle injury.

This claimant has an extensive prior medical history of neck and back injuries, in terms of medications that were taken in 2017.   It was noted that she was on anxiety medications, gabapentin, psychiatric medications.  She was an everyday smoker at that time.  She had neck and back issues with pain levels at the level of 8/10 as the worst pain in both the neck and back regions.  It was noted that she had chronic lumbar and right buttock pain for over ten years, with chiropractic care not helpful.

The claimant was being treated for anxiety, depression, with multiple psychiatric drugs, and also that she is a recovering alcohol abuser.  She was found to have positive straight leg raising tests on the right side.  Also, she had shoulder complaints, indicative of rotator cuff pathology.  She was also found to have carpal tunnel syndrome, left-sided, by her physician, Dr. Michael Weaver.

The claimant had ongoing care for her back and neck issues and carpal tunnel, with complaints of depression, alcohol abuse, back pain, neck pain.  It is noted she was in recovery for five years from her alcohol use.  It was noted also that she was having right-sided sciatica and left hand numbness, as of her June 2017 evaluation.

The claimant had continuing care with her providers.  She had pain, despite having epidural injections by Dr. Weaver.  Neck pain also persisted, with right shoulder complaints as well.  She also had a greater trochanteric bursa injection on the right side, because of her right hip complaints.

It was noted that the claimant had continuing pain despite chiropractic and anti-inflammatories with pain levels 8-9/10, as of 2019 evaluations.  It was also noted that the claimant had several falls and in her evaluation in October 2022, neck pain was persistent at that time as well, with hand numbness.

Baclofen was added to her regimen of care in 2022.  She had a caudal steroid injection 10/28/2022 by Dr. Cano, with some relief of pain.  Because of her continued issues with her neck, she had another MRI study on 06/21/2022, with 7/10 pain at worst.  Her back pain had improved as of that caudal block, but her neck pain persisted.

Further medical records noted from February 28, 2024, stated the claimant had received steroids for her motor vehicle accident and she had neck pain and was seen by chiropractor.  No mention was made of any back concerns.  The medical record indicates that she was rear-ended and her airbag did not deploy.

Records from Keystone Spine Management, 02/29/2024 notes that the claimant had neck complaints and some low back complaints as well.  It is also noted that the claimant has a history of trypanophobia, which means that she is afraid of needles and needs sedation for injections.

Follow up records from Dr. Evans notes the claimant was treating with a chiropractor who was helping with her back, but she still had some neck pain, worse on the left-hand side.  Dr. Evans continued to treat her with the medications of baclofen, anxiety medications, gabapentin, ibuprofen, prednisone on occasion, and also receiving psychiatric drugs.  Apparently, she has continued, as noted as of 10/20/2024, to have continuing neck complaints, some right arm complaints and that there was some improvement, but not back to baseline.  She also had some low back complaints as well.

01/29/2025, the claimant was again seen at Keystone Spine and Pain Management Center and it was noted that she had exacerbation of her chronic lumbar radiculopathy.  Epidural steroids were again recommended.  She would continue to do a home exercise program.  No significant change was seen from the prior MRI of the cervical spine from 2022, according to her treating physician, Dr. Steven Evans.  As of 05/12/2025, Dr. Evans notes that the claimant had an IME by a Dr. Perry, who disagreed with his conclusions.  The claimant had continued reporting of neck pain but was having some success with PT for her left-sided low back complaints.

The operative reports of her multiple injections going back to 2017 were noted and reviewed.

The claimant did ultimately have a left carpal tunnel syndrome, 11/22/2024, by Dr. Colin Vroome, and arthroscopic carpal tunnel release was performed.

Dr. Colin Vroome’s records were noted, indicating that she had bilateral carpal tunnel evaluation.  He notes the claimant had symptoms for several months, but this is not accurate, given her prior medical history.

Therapy records were noted, as listed in the index from several providers and chiropractors.

Impression:  

This woman did have a slight exacerbation of her neck and back degenerative changes after her low-grade motor vehicle injury.  Looking at her MRI studies and CT scans, both the images and the radiology review, I did not find any aggravation of her underlying arthritic changes in the neck or back region.  She had soft tissue complaints only.  In my opinion, these are fully back to her baseline.  Her buttock pain, in my opinion, is not explainable on her objective examination today.

The cervical and lumbar injections were unnecessary, not related and not properly indicated based upon the history, examination and medical record review. In terms of the chiropractic care, most patients will improve after the period of about six weeks after this type of injury and treatment following that period would not be reasonable or necessary based  upon the medical record review and my experience as an orthopedic clinician.

As of today’s examination, she has reached maximum benefit of treatment and needs no further care or treatment as it relates to her musculoskeletal concerns regarding the motor vehicle injury.  She has not had any permanent residuals from this motor vehicle injury.  She has no restrictions for her activities inside or outside of her home.  She does not need any further chiropractic care.  She does not need any further diagnostic studies.  She needs no further medical treatment as it relates to the incident from 12/05/2023.

All of the above opinions are given within a reasonable degree of medical certainty.

Sincerely yours,
Stuart L. Gordon, M.D.