Pennsylvania Workers' Compensation Lawyer Blog

While many injured workers with shoulder or neck pain do truly suffer from the initial diagnosis they are given, some have a more rare condition. Sure, a strain or sprain of the shoulder or neck is quite common, and the torn rotator cuff or labral tear in the shoulder, or disc herniation with radicular symptoms in the neck, is seen fairly often, but other conditions are seen on occasion as well.

In the September 2011 issue of the newsletter from Mink Radiologic Imaging, there is discussion of Parsonage-Turner syndrome (PTS), also known as acute brachial plexopathy. Additionally, this article mentions Quadrilateral Space Syndrome (QSS), another condition that could be considered in the presence of shoulder pain. The difficulty in clarifying a diagnosis in such a case is reflected in this article from The American Journal of Roentgenology.

These are things an injured worker, and, of course, his or her physician, should keep in mind if a presumed shoulder strain or sprain is not healing as would be expected. The continued presence of symptoms in the injured shoulder could be an indication of another, undiagnosed, condition.

Often, physicians who perform Independent Medical Examinations (IMEs), hired by the PA workers’ compensation insurance carrier, seem less than truly independent (I know, shocking, huh?). I have heard IME doctors over the years testify that a bulging disc is a natural finding, one that cannot cause symptoms, and cannot lead to nerve impingement. This, of course, is not the only view, as an article on Laser Spine Institute’s website demonstrates.

I also know another person who would disagree with the view shared by these doctors in the IME community. While Phillies pitcher Roy Oswalt does not have to worry about the Pennsylvania workers’ comp system (unlike most of us, he gets paid whether he works or not), he does have to live with the symptoms of a bulging disc.

As Mr. Oswalt described in this article on Philly.com, the bulging disc is sending pain down his leg. Interestingly, I have also heard IME doctors testify that a nerve being impinged or irritated by a disc (called “radiculopathy” or “radiculitis”) will cause pain along the entire course of the nerve, down to the foot. In this case, Mr. Oswalt noted that his pain has gradually gone all the way down the leg. Since he has no reason to magnify his symptoms (considering IME doctors would say injured workers always have a financial motivation to lie), this information from Mr. Oswalt is both reliable and persuasive.

This should be a reminder to Workers’ Compensation Judges throughout the State of Pennsylvania, that a bulging disc (even, as Mr. Oswalt has, a “mild” bulging disc) can cause debilitating symptoms that not only can sideline a pitcher, but can put a construction worker, warehouse helper, chef, secretary, nurse and any other job, out of work.

Several months ago, we posted a blog entry observing how diagnostic testing, MRI in particular, does not show “pain.” What can be seen on such studies are anatomical conditions which may or may not actually cause pain. We observed how this creates difficulty in litigation, such as a Pennsylvania workers’ compensation case, since an injured worker may testify that he or she suffers pain from an injury, but would be unable to “prove” it.

After the blog entry was posted, I was contacted by Dr. Donald Marks, whose company, Cognitive Engineering, LLC, maintains that they can “show” the pain an injured worker is feeling. Specifically, Dr. Marks stated, “Consider that a functional MRI can show actual activation of the pain centers of the brain, which validates/ illustrates the complaint of pain. I have published on this, and my work has supported two litigations.” You can see more about this concept on Dr. Marks’ website by clicking here.

This is a fascinating, and developing, area of medicine, which we, as attorneys who represent injured workers, will be keeping a close eye on.

Dealing with victims of work-related injuries every day, we understand that many of our clients need pain medications just to get through their days. Some of those prescriptions, however, are going to be changing, in an effort to make them safer.

Many pain medications combine an opioid, such as codeine, oxycodone or hydrocodone, with acetaminophen. In high doses, acetaminophen can cause liver damage, or even liver failure. Trying to combat these dangerous side effects, the U.S. Food & Drug Administration recently announced a limit on the amount of acetaminophen that can be used in these pain medicines (no more than 325 milligrams).

This change will be phased in over a period of three years, and no shortages of pain medicine are anticipated. Over the counter medications containing acetaminophen would not be effected by this action. If you have any questions about this action, or anything regarding the medications you take, you should always discuss such concerns with your doctor or pharmacist.

According to the American Academy of Orthopedic Surgeons, recent advances in hip replacements have made the procedure easier, and made the results last longer. All of the news is not good, however, as these advances may come with potential consequences.

Metal-on-metal hip replacements can dramatically improve a patient's quality of life, and return an injured worker to gainful employment. Unfortunately, the metal-on-metal hip replacements can also lead to cobalt toxicity. Patients getting metal-on-metal hip replacements may require some monitoring, or testing, after the procedure, to make sure cobalt levels are not unusually elevated.

The type of hip replacement performed, and, of course, whether a patient should even get a hip replacement at all, are discussions we encourage our clients to have with their orthopedic surgeons.

Though, generally speaking, Pennsylvania’s workers’ compensation system is based purely on wage loss, there are exceptions to the rule. With most work-related injuries in PA, workers’ comp is paid only if the injured worker is disabled from his or her job by the work injury.

One large exception is the category of injuries called “specific loss.” This encompasses when an injured worker permanently loses the use of certain body parts or senses. In this event, benefits are paid under the Pennsylvania Workers’ Compensation Act, whether or not there is any disability resulting from the injury. This covers fingers, toes, hands, feet, arms and legs, in addition to the senses of sight and hearing.

Loss of hearing has had many changes in PA workers’ compensation law over the years. In fact, the entire way hearing loss is compensated under PA workers’ comp was changed with Act 1, passed in 1995. For all hearing loss since then, the amount of workers’ compensation benefits paid varies according to the percentage of binaural (both ears) hearing impairment. To receive any workers’ comp benefits, there must be at least a 10% hearing impairment; while, on the other hand, an impairment over 75% is deemed to be a complete loss of hearing.

One issue that arises in hearing loss cases is the contribution of “presbycusis,” the name for the loss of hearing which happens naturally as we age. When addressing the impact of harmful noise-exposure at work in a hearing loss, we also look at the type of hearing loss, as there are different characteristics for different causes. Of course, we also look at other kinds of noise to which the injured worker may have been exposed (military, hunting, power tools, just for a few examples).

Often, a loss of hearing is an insidious, gradual, process, which is not discovered for several years. Indeed, in many of our clients over the years, the injured worker is the last to notice (the family, and friends, who deal with the injured worker, are typically the first to notice).

When the loss of hearing is not raised until after retirement, there can be additional issues arising. One of these issues was faced recently by the Commonwealth Court of Pennsylvania in City of Philadelphia v. Workers’ Compensation Appeal Board (Seaman).

In this case, the injured worker was a fireman in the City of Philadelphia for many years. Several months after he retired, a hearing loss test (known as an “audiogram”) revealed a significant loss of hearing. The injured worker filed a Claim Petition, which was granted by a Workers’ Compensation Judge (WCJ).

The PA workers’ compensation insurance carrier appealed to the Commonwealth Court of Pennsylvania, saying that the injured worker could not win, because he could not prove the extent of hearing loss on the date he retired. The Court, however, rejected this defense and affirmed the granting of the Claim Petition. Unless there was a previous hearing loss test done close in time to the retirement, showing a significantly lesser hearing impairment, there is no such burden on the injured worker, the Court found.

Even more recently, in a decision rendered November 19, 2010, the Commonwealth Court of Pennsylvania again addressed hearing loss in the matter of Joy Mining Machinery Company v. Workers’ Compensation Appeal Board (Zerres). Here, as in the Seaman case above, the WCJ granted the Claim Petition finding a work-related loss of hearing (13.125% hearing loss in this case).

The issues in the Zerres case were whether the injured worker could prove he was exposed to the harmful noise within the three years before a Claim Petition was filed, and whether the WCJ could properly give greater weight to the injured worker’s testimony about noise level than noise-level studies (called “dosimetry readings”) offered by the employer.

The Court affirmed the decision of the WCJ, finding that the testimony of the injured worker, without more, if believed by the WCJ, was sufficient both for the timing of the noise exposure, as well as the level of exposure. The Court noted that the dosimetry readings offered by the employer were not done on the person of the injured worker, nor were they done every day in every area, thus, the dosimetry readings did not prove to what extent the injured worker was actually exposed.

As Pennsylvania Workers’ Compensation attorneys, we see a wide variety of conditions faced by injured workers, from broken arms and legs to Complex Regional Pain Syndrome and Brachial Plexopathy, and everything in between. While the conditions plaguing these injured workers vary widely, there is one constant we see in case after case – chronic pain.

All too often, we see an injured worker become addicted to prescription pain medication. Nobody wants to live in pain, and often the first thing doctors try to relieve symptoms is a pill of one type or another. Many times, as the injured worker recovers from the work injury, and the pain relents, the need for the pain medication disappears. Unfortunately, when the work injury does not get better, and the pain becomes chronic, prescription pain medication may no longer be a viable alternative.

According to a recent article on Medical News Today, there are options aside from pain medication to relieve symptoms. Advances are being made in “neurostimulators,” small devices which are implanted to help block pain impulses from reaching the brain. There is hope that these, and other advances, may lessen the need for giving medications to injured workers in chronic pain.

A recent study published in the New England Journal of Medicine, reported by the Associated Press, found that amateur athletes (and by extension, victims of work injuries in PA), who have torn the anterior cruciate ligament (ACL) in their knee, actually do better by trying to rehab the knee before trying the surgical route.

According to the article, less than half of those in the study needed the ACL surgically repaired within two years. It appears the rehabilitation, alone, was enough in those cases.
"It seems that if you start out with rehabilitation only ... you have a good chance of ending up with an equally good outcome as if you had early ACL surgery," said Richard Frobell, of Lund University Hospital in Sweden, an author of the work.

While all situations in medicine are different, depending on the particular patient, and other factors, this article certainly suggests that an injured worker with an ACL tear should be in no rush to undergo surgery on his or her knee.

We are pleased to present a guest blog post from http://www.metropolitanmds.com regarding the use of acupuncture. We thought this may be of benefit to injured workers, who may be interested in exploring alternative areas for pain relief:

Acupuncture is one of the oldest forms of health care and treatments on the planet, but it still serves its purposes even today. Now, while inserting dozens of needles into your body doesn't seem like the most fun way to treat ailments, acupuncture is a tried and true therapeutic practice that has helped people deal with pain for centuries.

By inserting needles into various pressure points around the body, physical pain and stress can be relieved and even treated using acupuncture. For most, it's funny to think that sticking needles into the pain areas and pressure points of the body would be the answer, but when it comes to people who suffer from fibromyalgia and chronic fatigue syndrome, it might just be that.

New studies have shown that that acupuncture in certain areas of the body releases adenosine, which is a natural pain killer that is usually released after an injury. This allows people who are suffering from constant fibromyalgia to gain some much-needed relief.

By releasing adenosine, pain signals can be blocked from ever reaching the brain thus helping sufferers deal with their pain problems. This brings up a lot of questions about how much acupuncture has to do with adenosine release and if this is the reason that so many benefit from it. Yet, whatever the reason, studies have shown acupuncture to be great at treating the condition and helping the people who suffer from it.

From the fatigue angle, the study also went on to show that adenosine released from acupuncture has a lot to do with the regulation of the sleep cycle. By being able to regulate sleep correctly, chronic fatigue syndrome may be able to be properly treated and even fixed.

Acupuncture paired with the correct medicine can help both constant pain and fatigue, as new studies have gone on to show. This is good news for sufferers of both ailments, and goes to show that this ancient art of health may still have some new tricks to share.

By Rachelle Holmes of Chicago Breast Augmentation and Chicago Liposuction Center, MetropolitanMDs

“Water on the knee” is one of those phrases we hear that harkens back to years ago, like lumbago (low back pain) or causalgia (Reflex Sympathetic Dystrophy (RSD); now also known as Chronic Regional Pain Syndrome (CRPS)). Simply put, “water on the knee” is swelling (also called “effusion”) of the knee.

Like lumbago, for years people associated “water on the knee” with aging and related degenerative changes. For lack of a better term, years of wear and tear. A recent article on Medical News Today, however, points out that “water on the knee” is not just a sign of aging or degeneration.

In fact, the article states that trauma and injury can be causes of the knee problem. Interesting, doctors can study the fluid which is drained from the swollen knee, to gain some insight on the condition involved. For example, if the swelling is due to injury or trauma, there may be blood in the fluid. Bacteria in the fluid could point to infection as the source of the swelling. Some types of acids in the fluid may cause doctors to lean toward other causes, such as gout.

Regardless of the cause of the swelling, “water on the knee” is not something that stopped in years past.

In representing injured workers in Pennsylvania, we frequently see hearing loss cases. Many work environments require employees in those areas to be exposed to dangerously high levels of noise. Over a period of time, this can lead to a loss in hearing.

Tinnitus, perceived usually as a “ringing” in the ear, is a condition that can be seen along with a loss of hearing. Workers’ compensation insurance carriers often allege that tinnitus, when present, is not the result of noise exposure at work, but of another cause, such as heredity.

A recent article discussed on www.medicalnewstoday.com suggests that tinnitus is far less likely to be the result of inheriting bad genes than from environmental factors, such as noise exposure at work.

In Pennsylvania, hearing loss as a result of noise exposure at work is compensable, as long as the loss of hearing is greater than 10%. The amount of compensation one can receive for loss of hearing in PA is relative to the percentage of the hearing impairment.

Perhaps the most debilitating of conditions we see in Pennsylvania Workers’ Compensation cases are ones of Complex Regional Pain Syndrome (CRPS) [Formerly known as Reflex Sympathetic Dystrophy (RSD)]. The hallmark of this condition is severe and constant pain. Since there is no cure for CRPS/RSD, all doctors can do is try to relieve and manage the chronic pain.

An article in Medical News Today says that researchers at the Pain Research Institute have found that a low dose of intravenous immunoglobin (IVIG) can provide dramatic pain relief for around five weeks in almost half of the patients surveyed. While the research is still in progress, this certainly represents hope for the many folks inflicted with this horrible condition. Also, by understanding how this drug works on the human body, additional treatments could be developed.

According to the PhillyBurbs.com, Rothman Institute, a highly respected medical practice based in Philadelphia, PA, has now opened a private hospital in Bensalem, PA. The hospital, the first opened by Rothman Institute, will handle only orthopedic conditions. There are 24 beds in the facility, which also contains medical offices.

More information can be found on the website dedicated to the new hospital, known as The Bucks County Specialty Hospital. While this facility is the first hospital opened by Rothman Institute, the practice does have ten offices throughout the Philadelphia area. The headquarters is located at Thomas Jefferson University Hospital in Center City Philadelphia.

In the PA Workers’ Compensation system, we often see the workers’ comp insurance company doctors employ a fanatical reliance on “objective” diagnostic studies, at least when the results are negative. These doctors who perform Independent Medical Examinations (IMEs)[More accurately known as Defense Medical Examinations (DMEs)] use a negative study to say the injured worker must be fully recovered.

This view, of course, is far too simplistic and quite flawed. One could ask Kevin Curtis for confirmation. As many of you know, Kevin Curtis is a wide receiver for the Philadelphia Eagles. He has not been able to play football this year due to persistent pain in his knee. Repeated MRI studies of the knee were negative for any structural damage at all. Had Mr. Curtis been an injured worker, the IME/DME doctors would have said there is nothing wrong with him, and he can return to unrestricted work.

Yet, with millions of dollars hanging in the balance, Mr. Curtis remains unable to return to the field. In fact, the symptoms were so troubling to Curtis that he underwent arthroscopic surgery on his knee. This type of case should serve as a reminder to Workers’ Compensation Judges (WCJs), as well as to those doctors performing IMEs and DMEs, that no diagnostic test, whether x-ray, MRI or CT scan, is infallible. And, sometimes, when an injured worker says his or her knee (or shoulder, or back, or whatever) really hurts, even in the face of a negative study, maybe it really does still hurt.

Handling Pennsylvania workers’ compensation cases, we see a wide variety of work injuries. From problems with the neck and the back, to shoulders, elbows, knees, hands and everywhere in between. The one constant, though, is pain. Whether the injured worker has a herniated disc in the back, a broken arm, or a sprain or strain of a muscle, the injury usually involves pain.

To treat pain, and inflammation, in an acute work injury, doctors often prescribe non-steroidal anti-inflammatory drugs (or, NSAID for short). However, according to a recent article on The Medical News website, Transdel Pharmaceuticals, Inc. has a new approach which they say is safer and more effective for pain relief than standard NSAID medications.

Recent clinical testing has reportedly been successful for Ketotransdel, an alternative to standard NSAIDs (which are in the form of a pill that is swallowed). Ketotransdel has a transdermal delivery system (or, in other words, this medication is applied to the skin, not a pill to be swallowed).

According to lead clinical investigator Evan F. Ekman, M.D. and President of Southern Orthopaedic Sports Medicine and Medical Director of Palmetto Health Parkridge Surgery Center, Ketotransdel will provide effective pain relief without the risks of standard NSAID medications, “which are associated with gastrointestinal, cardiovascular and other medical problems."

Any advances in managing pain, even if only in the acute stage, is a benefit to the injured worker, not only in PA, but throughout our Country.

In Pennsylvania workers’ compensation, we see all sorts of injuries. Everything from a torn rotator cuff in the shoulder, to an ACL tear in the knee, to an amputation of a finger or toe, to a herniated disc in the neck or back – and everything in between. One thing common to many work injuries, though, is pain. Often, severe and chronic pain.

This pain causes many an injured worker to take prescription pain medication, narcotic pain medication, for the first time on a prolonged basis. Taking such a strong medication, for a long period of time, can be frightening for some. The fear of addiction to pain medication often clouds the judgment of an injured worker, perhaps causing the injured worker to suffer chronic pain needlessly.

A recent article on WebMD addresses seven myths with regard to prescription pain medication. This article offers some good information to those injured workers who are now dealing with these issues, perhaps for the first time. Given the misunderstandings and fears regarding narcotic pain medications, this article should be required reading for all injured workers in the PA workers’ compensation system.

Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD), is a debilitating condition we see in Pennsylvania workers’ compensation all too often. This condition, whose sufferers experience tremendous, unrelenting, burning pain, has been known to develop from traumatic injury. Even when a work-related traumatic injury is not too severe, CRPS and RSD can develop. Medical experts remain at a loss to explain why this condition strikes some, but not others.

There is no cure for CRPS or RSD. The best doctors can offer is trying to relieve the terrible pain. As we have discussed in previous blog entries, research is continuing on possible treatment options.

Now, it appears there is a study looking into whether Functional MRI (fMRI) may be of benefit to those inflicted with CRPS or RSD. This treatment may also be of benefit to patients suffering from fibromyalgia, neuralgia, neuropathy and migraine headaches.

With the dangers of Swine Flu on the minds of everyone, but perhaps especially the minds of those workers in the healthcare industry, this article from the Centers for Disease Control (CDC) may be of interest. Ironically, this article was posted on March 31, 2008, long before the current Swine Flu pandemic.

Raising this issue also brings to light that a healthcare worker in Pennsylvania who is stricken with an infectious disease as a result of his or her job is entitled to PA workers’ compensation benefits. We often see this type of case with Clostridium Difficile Colitis (C-Dif), Methicillin-resistant Staphylococcus Aureus (MRSA), and other infectious diseases which are known to exist in hospitals, nursing homes and other healthcare facilities.

If you suspect you have caught an infectious disease as a result of performing your job duties in PA, it is critical that you contact an experienced Pennsylvania workers’ compensation attorney.

An article in the New York Times, talking about how insurance company’s “Independent Medical Examiners” (IME) may not be acting truthfully, hit home to me. Though the article deals specifically with New York workers’ comp, their system is close enough to Pennsylvania’s that comparisons are valid.

While I urge folks to read the entire article, the part that was my absolute favorite was the insurance company doctor who said, “If you did a truly pure report, you’d be out on your ears and the insurers wouldn’t pay for it. You have to give them what they want, or you’re in Florida. That’s the game, baby.”

According to a recent article in the Journal of the American Academy of Orthopaedic Surgeons, physical therapy, combined with anti-inflammatory medication, is the most effective treatment for low back pain caused by degenerative disc disease.

As many injured workers know, one can have degenerative changes in their lumbar spine without even knowing. Once a work injury takes place, by lifting or twisting, or other common movement, the weakened lumbar spine becomes symptomatic. This results from the instability of the damaged discs.

According to the article, physical therapy helps by strengthening the surrounding muscles in the abdominal area and the lumbar spine, and by physically manipulating the spine. To obtain the best results, the patient has to remain active and use appropriate body mechanics.

As a doctor at an orthopedic clinic was quoted in the article as saying, “Surgery should be the last option, but too often patients think of surgery as a cure all and are eager to embark on it.”

In an interesting study, posted on www.medscape.com, patients with lumbar disc herniations have been found to recover better than those patients who refuse surgery to concentrate on medications, exercise and physical therapy. An injured worker suffering a herniated disc in his or her back (or neck, for that matter) is a frequent condition we see in PA workers’ comp cases. Often, the injured worker is undecided regarding whether to have surgery performed. This study should be interesting, and enlightening, reading for those injured workers.

The study, known as the Spine Patient Outcomes Research Trial (SPORT), appeared in the December 1, 2008 issue of Spine. This trial reviewed 1244 patient cases, from 13 American spine clinics, over a period of four years. Each patient had at least a six-week history of a herniated disc in the lumbar spine, causing both back and leg pain. The patients either underwent a surgical procedure (standard open diskectomy), or a course of medications, home exercises and physical therapy.

After the four-year period, the patients who had the lumbar surgery were statistically happier, and better recovered, than those who did not. The surgical patients had better relief of pain (by about 15 points on a 100-point scale), greater physical functioning (also by about 15 points) and lesser disability (by about 13 points). Overall, 79.2% of the surgical patients, and 51.7% of the nonsurgical patients, reported major improvements in their condition. The benefits of surgery were seen as soon as six weeks after the surgical procedure, and were found to last through the four years of the study.

Obviously, whether an injured worker should have lumbar surgery in any specific case depends on that particular individual. This is a major decision which the injured worker should carefully discuss with the medical professionals. Under the Pennsylvania Workers’ Compensation Act, an injured worker is not limited to any specific number of medical opinions. As such, we often advise our PA workers’ comp clients to seek a second, if not a third or fourth, medical opinion as to whether surgery would be in their best medical interests. It is also very important to keep your PA workers’ compensation attorney advised of any changes in your medical condition or treatment, such as surgery.

A recent article on www.emaxhealth.com noted that the U.S. Food & Drug Administration (FDA) has approved an extended-release version of the chronic pain medication, Ryzolt (sold under the name of “Tramadol”). Though Tramadol has previously been available, this simplified dosage is new. Unfortunately, chronic pain is something we see all too often in PA workers’ compensation cases.

This drug is used for managing moderate to moderately severe chronic pain. The extended-release form of the drug should allow patients to better control their pain over the course of the day. With both immediate-acting, and extended-release, parts, Tramadol hopes to provide better relief to chronic pain sufferers.

The article notes that chronic pain impacts approximately 75 million people in the United States, “more than diabetes, heart disease and cancer combined.”

Recently, two pharmaceutical companies, Genzyme Corporation and Osiris Therapeutics,
announced that they have joined to develop two adult stem cell treatments. These medications, known as Prochymal and Chondrogen, may be a valuable resource to treat a wide variety of conditions. Benefits from these treatments may include control of inflammation, development of tissue regeneration and prevention of scar formation.

Clinical trials for Prochymal are currently underway for Crohn’s disease, diabetes, chronic obstructive pulmonary disease (COPD) and acute myocardial infarction. Chondrogen, to interest of those injured workers suffering from persistent knee pain, is in clinical trials to treat osteoarthritis of the knee.

Genzyme is no stranger to development of treatments for knee injuries. In fact, the company developed and commercialized the first-ever cell therapy product approved by the FDA, Carticel, used in knee cartilage repair. Genzyme’s products also include Synvisc, used to address the pain associated with osteoarthritis of the knee. The hope is that Chondrogen can not only treat the osteoarthritic knee pain, but also may be able to actually cure the disease.

While ankle injuries are common in PA workers’ comp cases, we do not hear about total ankle replacements as much as we hear of total knee replacements or total hip replacements. Unfortunately, sometimes a work injury causes such damage to the ankle, or triggers the development of arthritis in the ankle, such that a total ankle replacement is necessary.

A recent article on the American Academy of Orthopaedic Surgeons‘ website talked of improvements in total ankle replacements. At this point, in the United States, only four types of implants are available for total ankle replacements. Each of these devices consists of only two components. This means there will not be much mobility in the ankle. Of course, the alternative, of fusing the ankle in one position, offers no movement at all.

Outside the United States, total ankle replacements are being done with a device containing three components, allowing greater mobility. FDA approval is being recommended for such devices to be approved for use in the U.S. The article suggests approval for these devices could come as soon as later this year.

As if an injured worker needed another reason to think of surgery as only a last resort, a recent article in Annals of Surgery journal noted that there is a discrepancy in the count of surgical instruments (including sponges) in nearly 13% of surgical procedures. This, of course, does not mean an instrument, or a sponge, is left in a surgical patient in 13% of procedures (that percentage is closer to 0.02%, or one in 5,000). Still, this seems like a staggeringly high percentage to have a miscount.

An article in Amednews.com suggests some solutions to reducing this figure. One is putting bar codes on sponges, which would then be scanned in and out. The count would then be automatic. The article suggests this would add only about $9.00 per surgical case. Another option is placing tiny radio-frequency identification (RFID) tags in the sponges. A wand could then be used to locate missing sponges, either inside a patient, or around the operating room. This would cost an additional $25.00 to $45.00 per surgical procedure.

While certainly no injured worker wants to rush into surgery, sometimes a work injury requires surgical intervention, whether it is a back surgery, a total knee replacement, or any other procedure. The hope is that these new technologies can make surgery safer, and less risky, for every injured worker.

One of the most common work injuries we see in PA is to the back, whether it is a herniated or bulging lumbar disc, an aggravation of degenerative disc disease, or a soft tissue injury, such as a strain or sprain. These injuries run from a minor strain, which can be cured by rest and medication, to a herniated disc encroaching on a lumbar nerve root, which can require injections and surgery.

When an injured worker has suffered a herniated lumbar disc, and is having pain or numbness down one or both legs (“radicular symptoms” or “lumbar radiculopathy”), surgery may be discussed. One of the more common procedures to relieve the pressure of a herniated lumbar disc pressing on a nerve root is called a discectomy, where the disc material is simply removed.

A recent article published in the Journal of Bone & Joint Surgery examined some previous studies regarding the timing and effectiveness of lumbar discectomies. One of the more interesting findings was that pain relief occurs first after a lumbar discectomy, followed by recovery of motor function (strength), then improvement in sensation. In other words, it is not unusual for the injured worker to continue to have abnormal sensation after surgery. This is an important thing to keep in mind after surgery, so that the injured worker does not feel as if his or her recovery is not going well.

Another interesting finding in the article is that once severe extensor weakness (in this case, the big toe) has begun, lumbar discectomy is not likely to help. In that situation, apparently the nerve has been damaged too badly by the pressure of the herniated disc.

Obviously, whether a patient needs surgery is a determination to be made between the patient and the doctor. Our role as workers’ compensation attorneys in Pennsylvania is to make sure our clients have that decision to make. In other words, we want to make sure the workers’ comp insurance company is covering the treatment the injured worker needs.

Many of those who are injured at work and receiving Pennsylvania workers’ compensation benefits are using, or have used, the Fentanyl Transdermal Patch (FTP). As with any medication, the injured worker often has questions regarding the usage of the Fentanyl patch. This set of Frequently Asked Questions about FTP may be of interest to those workers’ comp claimants who use this medication.

Thoracic outlet syndrome is a debilitating injury we see in Pennsylvania workers’ compensation cases. In this condition, the blood vessels and/or nerves in the arms may be compressed, causing various symptoms, including pain, numbness, tingling and a “cool” feeling in the arms.

There is no easy cure for thoracic outlet syndrome. No medication, surgery, or other treatment method seems universally able to help the injured worker with this condition.

Hope may be on the horizon, however. A study is currently underway, investigating whether an injection of BOTOX may be an efficient reliever of symptoms from thoracic outlet syndrome. While it will be some time before this treatment is approved by the FDA (if ever), this development is worth watching for those who suffer from this diagnosis.

The rotator cuff is where four muscles and several tendons form a covering around the top of the humerus, the upper arm bone, in the shoulder. While tears in this region of the shoulder can occur with the wear and tear of using the shoulder over years, a rotator cuff tear is also a common injury we see in Pennsylvania workers’ compensation cases. This type of injury can occur in many different ways, including lifting or falling on the shoulder. Even repetitive use of the shoulder at work over years can lead to a compensable work-related rotator cuff tear.

A torn rotator cuff is generally categorized as either small, medium, large or massive. Initial treatment for a tear usually consists of “conservative” (non-surgical) options, such as physical therapy, medications and/or injections. If these conservative methods do not relieve the problem, surgery may be indicated.

The problem comes with the “massive” rotator cuff tears. These tears used to be called irreparable. The injured worker was left with only two choices – either live with the pain and disability, or have a “debridement procedure” performed (this is a surgical procedure where the area is cleaned out, though the tear is not repaired). In the past, the injured worker remained on workers’ compensation benefits, and remained unable to perform ordinary daily activities of living, let alone work.

These days, though, the injured worker with a massive rotator cuff tear has some better choices. Technology has brought potential real solutions to the irreparable rotator cuff tear. One such method is the Latissimus Dorsi Tendon Transfer procedure, in which a tendon is borrowed from the patient’s arm or shoulder and used to replace the ruined one in the rotator cuff. This procedure is said to require less than two hours of surgery, and only entail a single overnight hospital stay. A study was performed on the effectiveness of this procedure recently, in part authored by local orthopedic surgeons Dr. Gerald Williams, Dr. Shawn Hennigan, Dr. Sami Kella and Dr. Joseph Iannotti.

Perhaps even more encouraging is the arthroscopic Graft Jacket Allograft procedure, which remains in its early stages. It appears one of the biggest advantages to this surgery is that the procedure is “arthroscopic,” where the cuts are only small holes, rather than the large incisions required for open surgery. Here, the patient’s torn rotator cuff is repaired with a human cadaver graft, in a procedure said to last about four hours.

While these new developments in treatment for rotator cuff tears offer hope to patients, including those on Pennsylvania workers’ compensation, it is always wise to consult with your doctor, to determine the best course of treatment for your particular case.

In Philadelphia, we recently heard of “prolotherapy” because Philadelphia Flyers’ player, Simon Gagne, who injured his head and neck, has said this treatment method has greatly improved his condition. When I saw that, I wondered if prolotherapy may be beneficial to an injured worker, especially one who has hurt the neck or the back. Workers’ compensation cases are littered with patients taking an abundance of medications, or getting multiple steroid, or other, injections into their spines. We could certainly use a less invasive treatment option.

Prolotherapy seems to involve injecting a substance into the injured area, causing an irritation in the area. This certainly seems an odd step to take (purposely irritating an already injured area), but the idea is that the irritation being caused leads to the area repairing itself. The substance being injected can vary by the type of prolotherapy being done.

As with any potential treatment option, workers’ compensation patients should always discuss the step with their doctor. While it is always good to have options for treatment, some treatment methods may be better than others for any given condition or patient, and your doctor is the best one to guide which treatment would be greatest treatment option.

It happens all too often. A worker suffers an injury to his or her neck or back. Though the injured worker never had neck or back pain before the injury, the workers’ compensation insurance company questions the claim. According to the workers’ compensation insurance carrier, the injured worker is suffering from “degenerative disc disease,” not a work injury. In reality, of course, it is the work injury which has made the degenerative disc disease start to cause pain. In Pennsylvania, an “aggravation” of a pre-existing condition, like degenerative disc disease, is considered a “new injury,” allowing an injured worker to collect PA workers’ comp benefits.

That is only half the battle, unfortunately. Once the degenerative disc disease has been made symptomatic by the work injury, the symptoms often do not stop. Frequently, the injured worker will try many “conservative” treatment options, such as medications and physical therapy. Failing that, doctors might try various types of injections, including epidural steroid injections. Sadly, though, time and again, the injured worker remains in pain despite these efforts.

Once the pain has continued for longer than six months, and various conservative treatment options have failed to reduce the symptoms, doctors start to talk about surgery as an option. There is no doubt that spinal surgery, whether for the neck or the back, is a last resort. As with any major surgical procedure, there are serious consequences which can result from such an operation. Moreover, there is no guarantee the injured worker will be any better after surgery.

In the past few years, there have been some new options when it comes to cervical or lumbar spine surgery. “Artificial disc replacement” is a procedure which is now available for both the neck and the back. Our spines are comprised of “discs.” One could think of these discs as jelly donuts. When a disc is damaged, the jelly leaks out of the donut, and the donut flattens (putting more strain on the discs above and below the damaged disc). Artificial disc replacement is designed to avoid the strain on other discs, by inserting an artificial disc where the damaged disc was.

The artificial disc used for the lumbar spine, Charite’, was approved for use by the FDA in October, 2004. Then, in July, 2007, the FDA approved Prestige for the cervical spine. As with any medical decision, tremendous thought should go into what action is best for any particular patient. The fact that new options are developing, to relieve the chronic pain faced by the injured worker, is very encouraging.

Regardless of whether we are seeing an injured worker suffering from a trauma to his or her arm, leg, neck, back, shoulder or any other part of the body, the common thing we are seeing is pain. Often, this is a chronic, unrelenting, pain. These are usually the cases when surgery either has been attempted and has not been successful, or when the doctors do not feel surgery would relieve the pain. Frequently, the only way to even take the edge off this excruciating pain is by taking pain-relieving medications, often narcotics.

One of the more “popular” narcotic medications used in Pennsylvania workers’ compensation matters is OxyCodone (OxyContin). The manufacturer of OxyContin, Purdue Pharma, has recently developed three new dosage strengths. These three new dosage levels now make a total of seven dosage strengths of OxyContin. In theory, this makes prescribing the proper dosage for every injured worker much easier.

With more usage of OxyCodone, and OxyContin, comes more abuse. Unfortunately for those injured workers who actually need this type of pain medication for relief, many people are using such drugs recreationally. Purdue Pharma has attempted to change the type of the OxyContin tablet, to make it less “useful” for recreational use, but so far, the FDA has not approved the changes. According to this article, there were 42.2 million prescriptions written last year for Oxycodone.

It seems like such a basic thing. An injured worker goes to the doctor and gets a prescription. Big deal, right? What is there to think about? Well, maybe it isn’t so simple after all. Maybe there are some questions an injured worker should be asking when getting a prescription. When I came across this article, I started thinking that some of these ideas make a great deal of sense. The article seemed like a valuable resource to both my injured clients and the general public. I guess you could sum up some of these hints by reminding yourself to know what medication you are taking, why you are taking it, how to take it and how your body reacts to the medication. I would suggest anyone getting a prescription filled review this article.

Reflex Sympathetic Dystrophy (RSD), also known as Complex Regional Pain Syndrome (CRPS) is a horrible condition we see all too often resulting from work injuries. This condition can develop from a traumatic work injury, even what previously seemed to be a relatively minor one. Scientists still do not seem to know why RSD or CRPS develops.

The hallmark symptom of RSD or CRPS is unrelenting, often burning, pain. This character of pain, called “neuropathic” pain, is caused by irritation of the nerves in the affected area. Frequently, there are also changes in the skin or fingernails of the area as well (known as “trophic” changes). Sadly, there is no cure for RSD or CRPS, and doctors simply try to manage the symptoms of the patient as best they can.

Research is continuing in this area, and there are some promising things on the horizon. A recent study, led by local RSD/CRPS specialist Dr. Robert Schwartzman, found that the drug ketamine, given in an anesthetic dosage, may relieve pain in RSD/CRPS patients who have failed with other treatments. Administration of ketamine while the patient is placed in a five-day coma has been successfully performed in other countries, but has not been approved as yet in the United States. Obviously, in the workers’ comp setting, treatment not approved by the FDA probably does not need to be paid for by the PA workers’ compensation insurance carrier.

An incurable, debilitating, condition like RSD/CRPS raises many issues in Pennsylvania Workers’ Compensation. Unfortunately, the Pennsylvania Workers’ Compensation Act was designed for injuries which will eventually heal. The system is not properly prepared to deal with a lifelong debilitating condition like RSD/CRPS, which makes the selection of lawyers experienced in PA workers’ compensation particularly important.

Though the reasons for the dramatic increase are not clear, it appears total knee replacements and total hip replacements are much more frequent now than in the past. According to an article on the American Medical Association website, total knee replacements increased 63% from just 1997 to 2004. Over that some period, total hip replacements were up 48%.

One of the potential reasons for the striking increase is the trend of the population to generally be both older and heavier, putting greater strain on these joints. Better technology in performing the total joint replacements has also been said to have increased the frequency with which the procedures are recommended by doctors.

From the perspective of patients, the total knee replacement or total hip replacement may appear to be a safer long-term way to treat their chronic pain than continued use of medications. This is especially true given the controversy, and apparent side effects, of the class of medications including Vioxx, Bextra and Celebrex, known as Cox-2 Inhibitors. An increase in the amount of advertising by the manufacturers of the artificial joints may also make patients more interested in having the total joint replacements done

While not dealing specifically with workers’ compensation, this information is still important to injured workers. Decisions on whether to get a total knee replacement, or total hip replacement, are common in work injury cases.

Though workers’ compensation insurance companies routinely deny that carpal tunnel syndrome is caused by work activities, a recent article suggests that about half of all cases of carpal tunnel syndrome are, in fact, related to work activities. According to the article, Carpal Tunnel Syndrome Treatment, approximately two million people in the United States suffer from carpal tunnel syndrome. An estimated 260,000 surgeries are performed each year to address the condition.

"Carpal tunnel syndrome . . . tends to affect people more frequently who use their hands excessively, such as pianists, concert violinists, hairdressers, computer operators, manual laborers, artists, sculptors, dentists, and even neurosurgeons," says James R. Bean, MD, American Association of Neurological Surgeons president-elect.

One of the common injuries we see in workers’ compensation cases is to the neck. A recent study published on Spineuniverse, a website dealing with neck and back pain suggests that acupuncture relieves neck pain as well as injection therapy does, without the use of any medication. Unfortunately, though, neither of these methods seems to work for even half of patients. According to the study, 43.6% of acupuncture patients described themselves as being at least satisfied with their treatment, as compared to 41.3% of injection patients. Since surgery is a last resort, acupuncture can at least be considered as an option to relieve neck pain.