To whom It may concern,

I am in receipt of your request for an Independent Medical Examination for the claimant.

Please understand, everything stated below is done so with a reasonable degree of medical certainty. I explained to the claimant that we are not initiating a physician-patient relationship and the claimant is aware of this fact. The claimant did present today accompanied by his wife.

I did review the medical records with the claimant as they were provided to me.

History of Injury:

A deposition completed 10/29/2024 confirmed that the claimant is currently working with Platinum Paving and Seal Coating at the same capacity as he was prior to the injury in question. He does confirm prior to his date of injury, he did go to the chiropractor for adjustments as needed. He did have four prior motor vehicle accidents without any reported injuries. He also noted that he fell down the steps in 1995, resulting in low back pain, but no active formal treatment. He does report that on 06/03/2022, someone ran a stop sign, hit his car, pushed him into oncoming traffic where he was involved in a second impact that was head-on in nature. There was no airbag deployment or loss of consciousness. His complaint at the time of the deposition was neck pain radiating into the shoulders. He did have low back pain that had resolved.

I reviewed the claimant’s history with the claimant. He confirms that he had no prior issues involving any musculoskeletal body part. He is currently employed at the same level and work capacity as prior to the injury. He is right-hand dominant. He did confirm that there was presence of low back pain that has since resolved.

He did inform me that he underwent a rhizotomy by a pain management physician at St. Mary’s Medical Center on 05/20/2025. He is unsure of the level of the rhizotomy, but he does confirm that this has helped his upper extremity issues. He currently complains of a sunburn sensation from the procedure itself. He was informed that this may take several more months to resolve.

With regards to the injury in question, he notes a tightness and pain in the neck that reaches 6-7/10 and radiates into the bilateral paraspinous musculature and into the lateral shoulders with an associated burning sensation. There is no specific numbness, tingling or bruising. He does feel that his neck may be swollen.

He is not currently in any active treatment except for follow-up with the pain management specialist, and he is currently taking ibuprofen as a pain medication.

Medical Record Review:

I have access to diagnostic reports from multiple imaging studies.

06/03/2022: CT of the head, cervical, thoracic and lumbar spines suggest no acute bony pathology or intracranial pathology.

06/03/2022: CT of the chest, abdomen and pelvis show no acute cardiopulmonary abnormality, but a stable 8 mm left upper lobe nodule, 11 mm thyroid nodule, slightly increased in size compared to prior exam, and no acute process in the abdomen or pelvis.

10/03/2022: MRI of the cervical spine confirms degenerative narrowing, disc space involving the C6-C7 level. The C3-C4 level demonstrates bulging of the disc and spondylosis without findings of herniation, minimally more pronounced on the right accompanied by early left greater than right neural foraminal degenerative narrowing, C4-C5 disc bulging and spondylolysis without herniation, with early left greater than right, neural foraminal degenerative narrowing, C5-C6, small central and right-sided disc protrusion and spondylosis with impingement limited to the thecal sac without cord compression being associated with mild to moderate right-sided neural foraminal degenerative narrowing and the left neural foramina being less extensively compromised. At C6-C7, minimal disc bulging without findings of herniation being associated with early left-sided neural foraminal degenerative narrowing and the right neural foramina being patent.

A second evaluation of the same MRI completed by Shaer Padilla Medical Imaging Consultants on 05/17/2025, suggests that there are multiple annular bulges with absent vertebral body remodeling as seen with osteoporotic or dramatic fractures, not present on this study, and bulging discs are due to disc degeneration and are unrelated to any single acute traumatic event, including the incident in question. There are protruding disc herniations and adjacent osteophytes at C4-C5 and C5-C6, and at each level, the herniation is equal in its signal intensity when compared with its disc of origin. These are longstanding, present prior to the incident. Had these occurred on the date of loss, the herniations would be of greater signal intensity than their respective discs of origin, indicating recent findings. Adjacent bone spurs requiring many months to years to form, support the chronicity of these findings. It states within this radiology report, “It is therefore my opinion, within a reasonable degree of medical certainty, that there is no imaging evidence of injury as a result of the accident of June 3, 2022.”

Claimant was evaluated by Dr. Gary Glassman at St. Mary’s Emergency Department on the date of incident where there was confirmation of seatbelt wear and lack of loss of consciousness or airbag deployment and the claimant was subsequently discharged on the same date.

Claimant was evaluated on 09/06/2022 at Patient First by Dr. John B. Junod, where there was noted to be no improvement with physical therapy and recommendations to follow up with Orthopedics.

Claimant then followed up with Dr. Stephen Cairone on 09/21/2022, where an MRI of the cervical spine and a Medrol Dosepak was provided.

Followup on 10/05/2022 confirmed a normal bilateral upper extremity examination with decreased cervical range of motion.

Claimant was then referred to pain management specialist, Dr. Gautam Kothari, who evaluated the claimant on 10/10/2022 and continued to treat him through 01/06/2024. During this time, the claimant underwent three separate C7-T1 epidural steroid injections on 10/28/22, 12/23/22 and 01/26/24.

I reviewed chiropractic notes authored from 06/16/2022 to 07/27/2023.

I reviewed physical therapy notes from 08/09/2022 through 10/02/2023. On the last visit, the claimant noted more good days than bad, and there was continued improvement.

There are family medicine notes that were reviewed as well, authored 09/22/2022, where there was a complaint of neck pain from a motor vehicle accident and a visit on 06/19/2023 which made no mention of musculoskeletal pathology.

Physical Examination:

Physical examination was completed today. Clinical inspection of the cervical spine shows no skin swelling, bruising or deformity. His overall range of motion, extension, flexion, side-to-side bending and twisting is within normal limits. There is no crepitus on motion. He does describe some mild tenderness to palpation to the paraspinous musculature. With Spurling’s maneuver he has some exacerbation of cervical spine pain, only subjectively reported.

Bilateral upper extremity examination is completely normal with regards to range of motion at the shoulders, elbows, forearms, wrists, and fingers with 5/5 strength of resisted motor function throughout. His light touch sensory function is currently intact, but he is describing a burning-type sensation along the lateral aspect of the arms that does not radiate past the elbow. He has a negative Hoffman exam, and his light touch sensory function is intact. He has a normal vascular exam. There is no muscular atrophy appreciated.

Lumbar range of motion is within normal limits without pain to palpation.

Bilateral lower extremity examination is within normal limits with regards to range of motion, strength, light touch sensory, and vascular function at the hips, knees and ankles. He currently walks with a normal gait and has a normal station.

Conclusions:

Based on the MRI report, subsequent evaluation completed by Shaer Padilla Medical Imaging Consultants and based on my review of his history and clinical exam, I do not believe this claimant has sustained any permanent injury as a result of the motor vehicle accident that occurred on 06/03/2022.

The claimant’s MRI findings are consistent with chronic pathology and pre-existed the accident in question. Therefore, the cervical pathology associated with the need for the three ESI and the rhizotomy is not related to the MVA.

All of his clinical findings today are subjective in nature, as he has a normal examination otherwise. I believe his treatment thus far has been appropriate.

Further treatment would be for the degenerative process within the cervical spine and not needed as a result of the MVA.

He is currently working at the same capacity as prior to the injury.

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

Sincerely yours,
David P. Hardeski, M.D.