Dear Ms. Wall:
   
   p.1.1
   At your request I reviewed medical records pertaining to William
   Hammel who was involved in a motor vehicle accident on 9/16/94.
   
   Records provided for review included:
   
     1. A copy of Mr. Hammel's deposition transcript of 2/25/98.
     2. Mr. Hammel's answers to interrogatories.
     3. Records from Dr. Peter Boulukos.
     4. Records from Dr. James Linder.
     5. Reports from Teaneck Radiology Center.
     6. Records from Dr. Peter Schmaus.
     7. Records from Dr. Albert Stabile.
     8. Records from Dr. Martin Kluger.
     9. Records from Dr. Paul Sender.
    10. Records from Dr. Gary Savatsky.
    11. Records from Andrews Family Chiropractic Center.
    12. Records from Smoky Mountain Center for Mental Health Developmental
        Disability and Substance Abuse Services.
    13. Records from Duke University Medical Center.
   

Mr. Hammel is a 55 year old gentleman who alleges injury following a motor vehicle which occurred on 9/16/94. According to records reviewed, he was a seatbelted front seat passenger in a vehicle operated by Alan Bellamente that apparently slowed down to turn into a driveway and then was hit from the rear.

Page 2

p.2.1
Records from Dr. Peter Boulukos a chiropractor described treatment on 9/17/94 for complaints of neck stiffness, right shoulder weakness, and pain in the right arm, left shoulder and lower back. I note that treatment continued through February of 1996.

p.2.2
Dr. Hammel was evaluated by Dr. James Linder, a physical therapist and chiropractor on 2/15/95. He documents that just prior to the impact, Dr. Hammel was adjusting himself in the seat and was slightly rotated to the left when the impact occurred. According to Dr. Hammel's deposition transcript, he was retrieving papers from the rear of the car. Dr. Linder documents that the patient was not rendered unconscious by the impact but felt shaken. He complained of neck pain and stiffness with low back pain appearing that evening which progressed the next morning prompting treatment with Dr. Boulukos. His complaints as of 2/15/95 included headaches, cervical area pain, pain in the right posterior shoulder travelling into the right upper arm and intermittent low back pain.

p.2.3
I note that Dr. Boulukos arranged for x-rays of the lumbar spine performed at Teaneck Radiology Center on 3/10/95 which were compared to outside films dated 9/17/94. The radiologist commented that there was no interval change compared to the earlier films in terms of degenerative spondylolisthesis which was felt to be due to ligamentous laxity. No gross instability was suggested on prone and supine films. Moderate spondylosis and degenerative disc space narrowing was noted specifically at T-12-L1 and L1-L2. The spondylolisthesis was described as involving L2-L3 and L4-L5. Please note that these degenerative changes which were documented to be present on the films of 9/17/94 were clearly degenerative disease, and longstanding information which in all medical probability was unrelated to the accident in question. X-rays of the right shoulder performed on 3/20/95 also showed degenerative change in the AC joint as well as a tiny bony density projecting along the inferior glenoid rim which was felt to be represent prior injury or possible loose body. There was no dislocation.

p.2.4
An MRI of the cervical spine peformed on 3/10/95, was interpreted as showing diffuse degenerative spondylosis encroaching on the ventral lateral subarachnoid spaces maximal at C6-C7 and also at C5-C6. A bulging disc and osteophyte at C6-C7 compromised the right lateral recess and right neural foramen. At C3-C4, osteophytosis resulted in mild right neural foraminal compromise without definite exiting nerve root compromise. Similar changes were noted at C4-C5 causing bilateral mild neural foraminal compromise, right greater than left. At C5-C6 the osteophytosis and broad based bulging disc resulted in severe encroachment of the right lateral recess and right neural foramen and likely exiting right nerve root. Moderate encroachment on the left neural foramen without nerve root compression was noted. At C6-C7, there was severe acquired central canal stenosis from posterior osteophytosis and bulging disc which also resulted in bilateral neural foraminal compromise with suspected encroachment on the right exiting nerve root. Please note that an x-ray envelope labeled "MRI of the cervical spine 3/10/95" was provided. That envelope actually contained 2 copies of a lumbar MRI of the same date with no copies of the cervical spine. Should copies of the cervical spine films become available, I would be happy to review them and issue a supplimental report if indicated. It is evident however

Page 3

p.3.1
from the radiologists detailed description that the changes seem to represent longstanding chronic degenerative disease unrelated to the accident in question. Please note that disc bulges are common in the general asymptomatic population even in the absence of trauma and are not considered significant. The osteophytic changes seen in this patient could very well be clinically significant based on the description or neural foraminal compromise. These osteophytic changes however were again long standing in formation in this 55 year old gentleman and in all medical probability were unrelated to the accident in question.

p.3.2
The MRI of the lumbar spine performed on 3/10/95 was described as showing a mild gibbous deformity at T1-T2 and L1 with step-ladder-like multilevel subluxationwhich was felt to be due to ligamentous laxity from T12-L1 through L5. Disc space narrowing was noted at T12-L1 and L1-L2 with prominent anterior osteophytosis at L1-L2.

Diffuse disc bulging was noted at L2-L3 and L3-L4 with uncovering of the disc from subluxation which was noted to flatten the ventral thecal sac.

Borderline mild acquired central canal stenosis was noted at L2-L3 with minimal encroachment on the lateral recesses but not the neural foramina. Mild facet hypertrophic changes were noted bilaterally at L3-L4.

p.3.3
Diffuse disc bulging was noted at L4-L5 abutting the ventral thecal sac with no lateral recesses or frank encroachment on exiting nerve roots. At L-5S1, disc bulging was noted as well with a superimposed small disc protrusion and annular tear central an to the right paracentral region effacing the epidural fat but not deforming the thecal sac. There was no evidence at that level of neural foraminal compromise and no description of any nerve root impingement.

I reviewed the actual films and agree with the presence of degenerative changes as described above.

The small central and right paracentral disc protrusion noted at L5-S1 and is consistent with the overall picture of degenerative disease and is not causing any nerve root impingement making the neurologic clinical significance of this finding doubtful.

Once again I point out that disc bulges and even small disc protrusions are seen commonly in the general asynptomatic population even in the absence of trauma. The changes seen on this MRI are chronic degenerative changes longstanding information which in all medical probability are unrelated to the accident in question.

p.3.4
When re-evaluated by Dr. linder on 3/5/95. the patient had no recent headaches and reported mild pain in the cervical region on a daily basis. He denied radicular pain, or sensorimotor disturbance in the upper extremities. He did complain of an increase the intensity of pain in the right shoulder region including clicking and cracking of the shoulder. He described mild pain in the lower lumbar region and did report an acute episode of pain lasting several days since last seen in Dr. Linder's office.

Overall, however, his low back pain generally improved although he was left with a dull achy sensation of his back and overall stiffness. No reference is made to any radicular pain down the legs.

p.3.5
An MRI of the right shoulder performed at Teaneck Radiology on June 14, 1995 was described as showing degenerative disease involving the acromioclavicular joint and glenohumeral joint. The radiologist was suspicious for a small tear involving the anterior glenoid labrum. The actual MRI films of the shoulder were

Page 4

p.4.1
provided, however intrepretation of MRI films of the shoulder lays outside my area of neurologic expertise. Apparently Dr. Peter Boulukos, a chiropractor did not consider ordering an MRI of the right shoulder outside his area of chiropractic expertise.

p.4.2
Mr. Hammel was in fact evaluated by Dr. Peter Schmaus, an orthopedist on 6/26/95 for complaints of right shoulder pain. He complained of intermittent neck pain at that time but denied any significant radiation of symptoms below the right elbow. He denied persistent distal numbness, tingling or paraesthesias. He apparently achieved relief with treatment with his chiropractic physician, Dr. Boulukos. Dr. Schmaus diagnosed rotator cuff injury.

p.4.3
A report from Dr. Albert Stabile described an evaluation of 5/7/97 for complaints of shoulder pain, neck pain and back pain. There is no description of any radicular pain down the arms or legs.

p.4.4
A report from Dr. Martin Kluger, a psychologist describes treatment from October 1995 through February 1996. The patient sought psychological treatment aleging that "his emotional condition worsened dramatically after the discontinuation of medical benefits by State Farm Indemnity of New Jersey. He felt unable to cope with the new and added stress." Dr. Kluger does not indicate who referred this patient to him.

Dr. Kluger's report make references to diminished memory and concentration. He described Mr. Hammel as a man who took great pride in his intellectual pursuits. He described him as an accomplished pianist who could no longer play well as a man who had a voracious appetite for philosophy, mathematics and physics who prior to the accident in question wrote many papers in these fields but was unable to be productive since the accident.

Dr. Kluger does not comment on Dr. Hammel's apparent difficulty to maintain regular employment commensurate with his academic credentials even prior to the accident in question.

p.4.5
Dr. Schmaus' note of 11/5/95 documents complaints of shoulder pain. At that time there was no significant pain below the elbow. The patient had no clear radiation from the neck in a cervical radicular pattern and denied numbness or tingling.

p.4.6
Dr. Schmaus referred the patient to Dr. Gary Savatsky, his associate who performed an initial examination of the shoulder on 11/29/95. He documents that the patient experienced pain at the lateral aspect of the shoulder and that he initially saw a chiropractor after the accident in question for over 50 visits.

p.4.7
A note from R. Colvard, a nurse clinician dated 4/16/96 describes depression and anxiety. Rita Colvard is associated with the Smoky Mountain Center for Mental Health Developmental Disability, And Substance Abuse Services. The patient denied prior psychiatric history but did indicate that he had a history of alcohol abuse 10 or 12 years previous after which he stopped drinking completely. Reference is made to his family practioner prescribing psychotropics and that the patient had stopped taking Effexor an anti-depressant, six or seven weeks prior to her evaluation. He continued on Klonopin, a benzodazpine as needed. She indicates

Page 5

p.5.1
that he had a Ph.D. in Theoretical Physics and was considering getting a job as a high school teacher. Ms. Colvard documents that while still in New Jersey tha patient had an EKG and was told of a left bundle branch block. I note her diagnosis of generalized anxiety disorder.

p.5.2
Notes from C.P. Laub who apparently is a counsellor at the Smoky Mountain Center were reviewed. Additional notes from a B. Beutell a child and family therapist associated with the Smoky Mountain Center were reviewed as well.

p.5.3
Dr Hammel was evaluated by Dr. Michael Haglund, a neurosurgeon at the Duke University Medical Center Clinic on 8/26/96. He indicates that Dr. Hammel was reaching back to get some paper work when his car was struck from behind. He commented that originally after the accident "everything was OK but that evening he noted a stiff neck and severe upper arm pain. He had similar pain down the left arm and he also had bilateral leg pain radiating to his thighs and into a four dermatomal pattern."

The patient complained of spasms in his legs and pain in his arms involving all 10 digits of the hands but said that mainly the pain stayed in his neck and arm area and and radiated to the middle three digits. He denied lower extremity paraesthesias or bowel or bladder problems.

Dr. Haglund reviewed MRI films [of 03/10/95] showing multilevel stenosis and degenerative disease including foraminal narrowing and retrolisthesis. Dr. Haglund recommended proceeding with surgery in the cervical region involving a C3-C6 laminectomy and foraminotomies and then performing lumbar decompression 4 to 6 weeks later.

His note establishes no causal relationship between the need for this surgery and the accident in question.

A subsequent note however, to the patient's attorney dated 10/22/96 indicates that it was his opinion that the accident exacerbated a pre-existing condition.

It appears that he based this on Dr. Hammel's subjective complaints which by history began after the accident in question. He concluded "the MVA seems to have played a key role in causing the patient's current pain and syndrome."

He does not indicate that the accident had any role in causing the patient's considerable degenerative changes.

On physical examination [08/26/96] Dr. Haglund noted some weakness in the biceps and triceps with positive straight leg raising at 30 degrees on the right and 45 degrees on the left.

He does not comment whether the straight leg raising test was performed in both the supine and upright positions.

He did comment on subjective complaints of decreased pinprick in an L3-L4 and slight L5 distribution with corresponding decrease in temperature perception. The patient also reported decreased pinprick and temperature in the C5-C6 dermatome with normal vibration and touch. Reflexes were described as diminished in the triceps and knee. Toes were downgoing and Hoffman's sign was negative. Cerebellar and Romberg's testing was normal.

p.5.4
Records from Barbara Dobrowski also of the Smoky Mountain Center for Mental Health were reviewed.

I note that Dr. Hammel was admitted to Duke University Medical Center on 5/13/97 through 5/16/97. They document a past surgical history

Page 6

p.6.1
of an extensor digitorum release and deviated septum repair. If any other records documenting any prior trauma in this patient become available, I would be happy to review them and issue a supplemental report if indicated. The patient during that admission underwent a C-3 through C-7 posterior laminectomy and did well postoperatively. His principal diagnosis was cervical stenosis.

The operative report describes laminectomies at C3, C4, C5, C6 and C7 with bilateral foraminotomies especially at C5-C6.

No reference is made in the operative report to any disc herniation or nerve root impingement.

p.6.2
Postoperative notes from Dr. Haglund dated 6/23/97 describe a good postoperative course with almost complete relief of pain and tingling in his hands. Dr. Haglund indicated "as I noted at the time of the operation, he did have a lot of muscle disruption suggesting a previous trauma to his neck" I note that the operative report makes no reference to any muscle abnormality.

Dr. Haglund does not further explain what he means by" muscle disruption." Dr. Haglund's note of 10/25/97 makes reference to a complaint of "total body numbness with some weakness and tingling in his hands." A hand written note indicates that the total body numbness was alleviated by hyperextending the neck. He commented "he still has L2-L3 retrolisthesis on his films, but this retrolisthesis was present back in in 1986 prior to the accident." Flexion and extension cervical films showed no evidence of any change, once again the multilevel degenerative disc disease with some foraminal narrowing at C5-C6 and C6-C7 was noted as well as retrolisthesis with degenerative disc disease at T12 through L3.

p.6.3
Dr. Haglund's note of 5/11/98 describes complaints of a burning sensation in the hands with decreased coordination. At that point he apparently was on Neurontin and was having increasing problems with activities of daily living. He described trouble walking and some weakness. He complained of constipation and losing urinary control. On examination his motor strength was 5-/5 throughout with some giveaway strength as well as decreased pinprick in the C7 distribution more on the left than the right. He had diminished vibratory sensation in a stocking-like distribution in the feet. He underwent an an EMG on 5/11/98 which according to Dr. Haglund showed no evidence of any peripheral neuropathy. Despite the normal EMG nerve conduction study Dr. Haglund suggested that the dysfunction of the hands and feet "go along clearly with some type of traumatic injury and the degeneration of the spinal cord itself." He does not support this conclusion with any more specific description of what type of traumatic injury caused these symptoms nor does he document any radiographic evidence of spinal cord atrophy or degeneration. He suggested that the patient be considered for 25% cervical impairment with some long tract signs. His report however, does not document any long tract signs and in fact commented on previous examinations that the patient's toes were downgoing and Hoffman's sign were negative.

Clearly Dr. Haglund's conclusion is entirely inconsistent with his physical examinations.

I reviewed the actual EMG nerve conduction report and note that the examiner described this as a normal study.

p.6.4
When seen by Dr. Haglund on 10/19/98, he had continued complaints of burning in his hands inteerfering with various activities and instability with walking. Dr. Haglund indicates that he discussed the patient's spinal cord degeneration and

Page 7

p.7.1
myelomalacia that occurrd because of his compressive syndromes and said that these could be either compressive or vascular.

I once again point out that I have no record of any cervical MRI scan showing or operative report documenting any spinal cord degeneration or myelomalacia.

I do note that Dr. Haglund considered these alleged findings either compressive or vascular apparently making no reference to any contribution from the alleged trauma.

He said the patient was going to see a urologist for erectile dysfunction and trouble with urination.

p.7.2
A letter from Dr. Haglund to the patient's attorney, dated 11/20/98 again makes reference to a 25% permanent partial impairment rating for cervical impairment with long tract signs.

I again point out that Dr. Haglund's note fail to document any long tract signs.

He added "I believe he has myelomalacia of the spinal cord which was exacerbated significantly by the MVA."

I once again note that no radiographic study ever showed any myelomalacia nor does Dr. Haglund indicate why he felt a single cervical sprain or whiplash injury was playing a significant role in this patient's cervical degenerative disease which clearly was long standing and many years in formation.

He felt that the patient's condition could either get worse or stabilize over time. A follow-up note of May 19, 1999 reiterated his opinion that "the atrophy of his spinal cord was exacerbated by the MVA and further compromised by delaying his cervical decompression." Once again, should any radiographic reports or films documenting any atrophy of the spinal cord become available. I would be happy to review them and issue a supplimental report if indicated.

IMPRESSION:

p.7.2
Review of the extensive records provided, reveals chronic degenerative disease in both the cervical and lumbar regions in this patient which in all medical probability predates the accident in question.

The cervical degenerative disease could explain Dr. Hammel's neck, arm and finger complaints which I note improved following surgery.

The surgery relieved neural foraminal stenosis caused by years of chronic degenerative change unrelated to the accident in question.

Dr. Haglund's references to myelomalacia, spinal cord atrophy, and long tract signs in letters to the patient's attorney are simply unfounded based on his notes which fail to document any long tract signs on examination and which fail to include any radiographic evidence of spinal cord atrophy or myelomalacia.

p.7.3
It is evident from reviewing Dr. Hammel's deposition testimony and medical records that he displays a tendency to blame all of his problems occurring after the accident in question on the accident.

He appears to believe that his inability to maintain employment, his heart attack, his need to move to North Carolina, his emotional complaints, and need for surgery were all the result of the accident in question.

This post hoc ergo propter hoc argument is simply fallacious.

By history he suffered a cervical sprain which would have been expected to resolve with time.

Furthermore, his chronic degenerative disease in both the cervical and lumbar spine would have been expected to progress with time even in the absence of any additional trauma.

p.7.4
It appears in reviewing the above records that Dr. Hammel viewed any physician

Page 8

p.8.1
or for that matter any attorney who did not agree with his views of the accident being the cause of all of his problems was incompetent or inappropriate.

p.8.2
As commented above, should the actual cervical spine MRI filma become available, I would be happy to review them and issue a supplimental report if indicated. The same is true for any other medical records that may come to light.

p.8.3
It is my conclusion based on the medical records reviewed thus far however, that Dr. Hammel suffered no permanent neurologic injuries as a result of the accident in question and that his cervical surgery was not necessitated by the accident in question.

   
   					Yours truly,
   
   
   					Eric L. Fremed, M. D.
   					Diplomate, American Board of
   					Psychiatry and Neurology
   
   ELF/tp
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