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FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
EXHIBIT AA
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
Sports & Entertainment Physicians, P.C.
Andrew N. Bazos, M.D.
Diplomate, American Board of Orthopedic Surgery
August 25, 2021
Ms. Yacine Williams, Paralegal
Kiernan & Trebach
40 Exchange Place, Suite 1600
New York, NY 10005
Email: ywilliams@kiernantrebach.com
CLAIMANT: Kelley Phillips
DATE OF LOSS: June 3, 2010
FILE NUMBER: 1978.0009
INDEPENDENT MEDICAL RECORD REVIEW and EXAMINATION
To Whom It May Concern:
PURPOSE:
At your request, I performed an independent medical record review and
examination (08/19/21) of the claimant, Kelley Phillips, and injuries she allegedly
sustained in an accident dated June 3, 2010.
REVIEW OF MEDICAL RECORDS: In forming my opinions, I relied upon the
following medical records:
1. Verified Bill of Particulars dated March 27, 2014.
2. Supplemental verified Bill of Particulars dated April 27, 2014.
3. Supplemental verified Bill of Particulars dated October 17, 2014.
4. Supplemental verified Bill of Particulars dated April 24, 2015.
5. Supplemental verified Bill of Particulars dated May 19, 2021.
6. X-ray of the pelvis report from Montefiore Hospital dated June 30, 2010.
7. X-ray of the lumbar spine report from Montefiore Hospital dated June 30, 2010.
8. X-ray of the cervical spine report from Montefiore Hospital dated June 30, 2010.
9. MRI of the lumbar spine report for Montefiore Hospital dated July 2, 2010.
10.MRI of the cervical spine report from Montefiore Hospital dated July 7, 2010.
11.Memo from Ashley Moloney, PA-C, dated August 20, 2010.
12.Medical records from Sireen Gopal, M.D., dated September 28, 2010, through
July 28, 2011.
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
Page 2
13.Operative report regarding lumbar paravertebral facet joint injections by Sireen
Gopal, M.D., dated October 20, 2010.
14.CT scan of the cervical spine report from Montefiore Hospital dated November
1, 2010.
15.CT scan of the head report from Montefiore Hospital dated November 1, 2010.
16.MRI of the brain report from Montefiore Hospital dated November 3, 2010.
17.MRI of the lumbar spine report from Montefiore Hospital dated November 3,
2010.
18.MRI of the cervical spine report from Montefiore Hospital dated November 3,
2010.
19.Operative report of a lumbar epidural steroid injection by Sireen Gopal, M.D.,
dated November 17, 2010.
20.Operative report regarding transforaminal lumbar epidural steroid injection by
Sireen Gopal, M.D., dated December 1, 2010.
21.CT scan of the cervical spine report from Montefiore Hospital dated January
22, 2011.
22.CT scan of the head report from Montefiore Hospital dated January 27, 2011.
23.X-ray of the right knee report from New York Spine and Sport Rehabilitation
Medicine, P.C., dated March 8, 2011.
24.Operative report regarding cervical facet joint medial branch block/injection by
Sireen Gopal, MD, dated April 14, 2011.
25.Operative report regarding cervical/thoracic facet joint injection by Sireen
Gopal, M.D., dated May 24, 2011.
26.Medical records from Health First Medical Group dated June 1, 2011, through
February 7, 2014.
27.MRI of the cervical spine report from Palm Bay Hospital dated July 23, 2011.
28.Medical records from Lynette M. Graff, M.D., dated September 26, 2011,
through November 29, 2012.
29.Letter from Kelley Phillips, M.D., to Maria Svark dated October 27, 2010.
30.Operative report regarding cervical facet joint medial branch block/injection by
Sireen Gopal, M.D., dated March 2, 2011.
31.Medical records from Gary Weiss, M.D., dated October 17, 2011, through July
20, 2020.
32.Medical records from Laurel McHone, MS, dated March 15, 2012, through May
12, 2014.
33.Medical records from Palm County Community Hospital Emergency Department
dated July 13, 2012.
34.Ultrasound of the abdomen report from Health First Medical Group dated
August 29, 2012.
35.Medical records from Palm Bay Hospital dated September 6, 2012, through
September 10, 2012.
36.X-ray of the cervical spine report from Palm Bay Hospital dated September 10,
2012.
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
Page 3
37.X-ray of the lumbar spine report from Palm Bay Hospital dated September 10,
2012.
38.MRI of the lumbar spine report from Palm Bay Hospital dated September 10,
2012.
39.Medical records from Scott Z. Seminer, M.D., dated January 8, 2013, through
February 5, 2013.
40.MRI of the cervical spine report from Weiss & Newberry Medical Associates
dated July 2, 2013.
41.X-ray of the right knee report from Health First Medical Group dated July 26,
2013.
42.Ultrasound of the abdomen report from Atlantis Diagnostics dated January 15,
2013.
43.CT scan of the cervical spine report from Palm Bay Hospital dated November
20, 2013.
44.X-ray of the lumbar spine report from Palm Bay Hospital dated November 20,
2013.
45.Chest x-ray report from Health First Medical Group dated December 27, 2013.
46.MRI of the brain report from Weiss & Newberry Medical Associates dated
February 26, 2014.
47.Medical records from BACK Authority for Contemporary Knowledge dated
March 17, 2014, through July 1, 2015.
48.Operative report regarding lumbar fusion at L4-L5 and L5-S1 by Devin Datta,
M.D., dated March 28, 2014.
49.Operative report regarding C6-C7 disc replacement by Devin Datta, M.D., dated
August 15, 2014.
50.MRI of the cervical spine report by Weiss & Newberry Medical Associates dated
February 2, 2015.
51.Medical records from Brevard Orthopaedic Spine and Pain Clinic, Inc., dated
July 29, 2015, through March 13, 2017.
52.Operative report regarding anterior cervical discectomy and fusion at C4-C5
and C5-C6 by Devin Datta, M.D., dated November 13, 2015.
53.CT scan of the lumbar spine report by NeuroSkeletal Imaging dated April 14,
2016.
54.Operative report regarding removal of lumbar hardware by Devin Datta, M.D.,
dated June 3, 2016.
55.CT scan of the cervical spine report by NeuroSkeletal Imaging dated June 13,
2016.
56.CT angio of the thorax from Palm Bay Hospital dated July 3, 2016.
57.Chest x-ray report from Palm Bay Hospital dated July 3, 2016.
58.X-ray of the lumbar spine report from NeuroSkeletal Imaging dated September
20, 2016.
59.Operative report regarding cervical epidural steroid injection by Devin Datta,
M.D. dated September 20, 2016.
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
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60.Chest x-ray report from Palm Bay Hospital dated September 26, 2016.
61.Chest x-ray report from Palm Bay Hospital dated October 1, 2016.
62.Operative report regarding cervical epidural steroid injection by Hicham Samir
Merheb, M.D. dated October 4, 2016.
63.MRI of the lumbar spine report from Palm Bay Hospital dated October 12, 2016.
64.Operative report regarding lumbar epidural steroid injection at L5-S1 by
Hicham Samir Merheb, M.D., dated October 19, 2016.
65.CT scan of the head report from Palm Bay Hospital dated October 25, 2016.
66.MRI of the thoracic spine report from First Choice dated December 20, 2016.
67.Operative report regarding lumbar epidural steroid injection at L5-S1 by Devin
Datta, M.D., dated March 13, 2017.
68.X-ray of the lumbar spine report from Palm Bay Hospital dated August 27,
2017.
69.MRI of the cervical spine report from Palm Bay Hospital dated August 29, 2017.
70.MRI of the brain report from Palm Bay Hospital dated August 29, 2017.
71.CT scan of the cervical spine report from Palm Bay Hospital dated August 30,
2017.
72.X-ray of the thoracic and lumbar spine report from Palm Bay Hospital dated
September 16, 2017.
73.MRI of the thoracic spine report from Weiss & Newberry Medical Associates
dated September 26, 2017.
74.MRI of the cervical spine report from Weiss & Newberry Medical Associates
dated September 26, 2017.
75.MRI of the brain report from Weiss & Newberry Medical Associates dated
September 27, 2017.
76.MRI of the lumbar spine report from Weiss & Newberry Medical Associates
dated October 10, 2017.
77.Fluoroscopically guided lumbar spine puncture report from Palm Bay Hospital
dated November 9, 2017.
78.MRI of the brain report from Weiss & Newberry Medical Associates dated
January 16, 2018.
79.MRI of the brain report from Weiss & Newberry Medical Associates dated May
10, 2018.
80.MRI of the cerebrals report from Weiss & Newberry Medical Associates dated
May 15, 2018.
81.MRA of the carotids report from Weiss & Newberry Medical Associates dated
May 15, 2018.
82.Operative report regarding placement of spinal or similar generator left flank
by Devin Datta, M.D., dated June 29, 2018.
83.MRI of the cervical spine report from Weiss & Newberry Medical Associates
dated January 15, 2019.
84.MRI of the lumbar spine report from Weiss & Newberry Medical Associates
dated January 22, 2019.
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
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85.MRI of the brain report from Weiss & Newberry Medical Associates dated
January 4, 2019.
86.Operative report regarding lumbar and cervical epidural steroid injections by
Devin Datta, M.D., dated August 2, 2019.
87.Medical records from Montefiore Medical Center dated February 1, 2009,
through March 26, 2010.
88.MRI of the cervical spine report from Montefiore Hospital dated April 7, 2010.
89.MRI of the brachial plexus, right side report from Advanced Imaging - Gun Hill
Road dated April 8, 2010.
90.MRI of the cervical spine report from Advanced Imaging - Gun Hill Road dated
April 8, 2010.
91.Deposition of Kelley Phillips dated November 18, 2011.
92.Deposition of Kelley Phillips dated July 27, 2016.
HISTORY:
The claimant is a 31-year-old female who, on June 30, 2010, had x-rays of the
pelvis, lumbar spine, and cervical spine performed at Montefiore Hospital. Both
studies of the pelvis and lumbar spine revealed no acute fracture, dislocation, or
subluxation. The cervical spine revealed minimal grade 1 retrolisthesis of C4 on
C5. She had an unremarkable examination of the dorsal spine.
On July 2, 2010, an MRI of the lumbar spine was performed at Montefiore Hospital.
The impression revealed small and left paracentral disc protrusion at L5-S1. No
central or foraminal impingement.
On July 7, 2010, an MRI of the cervical spine was performed at Montefiore
Hospital. The impression revealed unremarkable examination of the cervical spine.
On August 20, 2010, a pain management appointment request from Ashley
Moloney, PA-C, stated that the claimant was a 32-year-old female with a history
of a motor vehicle accident in December of 2008 and June of 2010, who has a
history of chronic back pain.
On September 28, 2010, the claimant presented to Sireen Gopal, M.D., with chief
complaints of neck pain, lower extremity pain, and back pain. The claimant stated
she had pain in her neck area radiating down into the bilateral posterior shoulders
and pain in the lower back. The claimant’s past medical history was positive for
anxiety disorder, migraine headache, and motor vehicle accident. Physical
examination of the lumbar spine revealed restricted range of motion, trigger
points, and pain. Straight leg raise and Fabere tests were negative bilaterally.
Deep tendon reflexes, muscle strength, and sensory were all normal. Cervical
spine examination revealed limited range of motion, myofascial trigger points, and
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
Page 6
Spurling’s, Babinski and Hoffman’s tests were all negative. Upper back evaluation
revealed myofascial trigger points bilaterally. The claimant was diagnosed with
lumbar spine herniated nucleus pulposus; backache, not otherwise specified;
cervical neck disorders/symptoms; unspecified myalgia and myositis.
On September 30, 2010, the claimant returned to Dr. Gopal’s office for an initial
physical therapy evaluation. Her working diagnoses were lumbar spine herniated
nucleus pulposus; backache, not otherwise specified; cervical - neck
disorder/symptoms; and unspecified myalgia and myositis.
On October 20, 2010, Dr. Gopal performed lumbar paravertebral facet and joint
injections at L3-L4, L4-L5 and L5-S1, left-sided.
On November 1, 2010, Dr. Gopal performed a transforaminal lumbar epidural
steroid joint injection. No levels were disclosed.
On November 1, 2010, a CT scan of the head was performed at Montefiore
Hospital. The impression revealed normal non-contrast CT of the brain.
On November 1, 2010, a CT scan of the cervical spine was performed at Montefiore
Hospital. The impression stated that prominent soft tissue along the posterior
margin of the odontoid process may represent underlying soft tissue or
ligamentous injury. No discrete fracture. If symptoms persist, an MRI of the
cervical spine was recommended to evaluate for soft tissue and/or ligamentous
injury; normal atlantoaxial interval.
On November 3, 2010, an MRI of the brain was performed at Montefiore Hospital.
The impression stated unremarkable enhanced MRI of the brain.
On November 3, 2010, an MRI of the lumbar spine was performed at Montefiore
Hospital. The impression stated that at L5-S1, there was an asymmetric disc bulge
to the left causing compression of the left S1 nerve root.
On November 3, 2010, an MRI of the cervical spine was performed at Montefiore
Hospital. The impression stated that there was no acute fracture or dislocation.
Mild disc bulges were noted at C4-C5 through C6-C7.
On November 17, 2010, the claimant presented to Amy Phillips, PA, at the office
of Sireen Gopal, M.D., for a follow-up appointment after hospitalization. The
claimant was noted to have just been discharged from the hospital status post
slip-and-fall in her bathroom. She remained in the hospital from November 1,
2010, through November 16, 2010 for postconcussive syndrome, nausea and
vomiting. Physical examination revealed tenderness in the bilateral lumbar facets
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
Page 7
with trigger points. Lumbar range of motion was limited. Straight leg raising and
Patrick/Fabere test was negative bilaterally. Bilateral upper and lower extremities
revealed normal strength, sensory, and deep tendon reflexes. Babinski was
negative. The claimant was diagnosed with cervical - neck disorder/symptoms,
not otherwise specified; lumbar spine herniated nucleus pulposus; unspecified
myalgia and myositis; and lumbar radiculopathy. A transforaminal lumbar epidural
steroid injection was performed.
On December 1, 2010, Dr. Gopal performed a transforaminal lumbar epidural
steroid injection at L5 and S1.
On January 27, 2011, a CT scan of the cervical spine was performed at Montefiore
Hospital. The impression stated there was no evidence of acute fracture or
subluxation, no intracranial hemorrhage.
On March 2, 2011, Dr. Gopal performed a cervical facet joint medial branch
block/injection at C3, C4, and C5.
On March 8, 2011, x-rays of the right knee were performed at New York Spine and
Sports Rehabilitation Medicine, P.C. The impression revealed no acute fracture.
On March 21, 2011, the claimant returned to Dr. Gopal for a follow-up examination.
All chief complaints, physical examination findings, and diagnoses were unchanged
with the exception of right knee pain. The examination revealed limited range of
motion and tenderness on the right medial joint line. The claimant was diagnosed
with cervical - neck disorder/symptoms, not otherwise specified; backache, not
otherwise specified; cervical spondylosis without myelopathy; chondromalacia of
the patella; lumbar spine herniated nucleus pulposus; and unspecified myalgia and
myositis. Trigger point injections were performed in an undisclosed location.
On April 14, 2011, Dr. Gopal performed a cervical facet joint medial branch
block/injection at left-sided C2, C3, and C4.
On May 24, 2011, Dr. Gopal performed a cervical/thoracic facet joint injection.
On June 1, 2011, the claimant presented to Joe O. Littlejohn, M.D., at Holmes
Family Medical Group with a chief complaint of urinary retention. The only
significance to this file is the disclosure of the claimant stating that she had two
previous head traumas after drinking alcohol while on a muscle relaxant, passing
out and hitting her head.
On July 23, 2011, an MRI of the cervical spine was performed at Holmes Regional
Medical Center. The impression revealed multilevel mild disc bulges as discussed
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
Page 8
without significant change from prior study.
On July 8, 2011, the claimant presented to Amy Phillips, PA, at New York Spine
and Sports Rehabilitation Medicine, P.C. The claimant was there for a follow-up,
complaining of pain in the neck radiating into the bilateral posterior shoulders with
numbness in the left medial forearm and upper middle back and pain in the low
back with non-radiation. Physical examination revealed the claimant was alert and
oriented x3. Her gait was normal, no edema or skin lesions. Physical examination
of the cervical, thoracic, and lumbar spine revealed restricted range of motion with
tenderness to palpation and spasms. Deep tendon reflexes were equal,
symmetrical, and bilateral. Examination of the right knee revealed limited range
of motion, no swelling or redness. There was tenderness to palpation along the
lateral joint line. Grind test was positive. She was diagnosed with cervical
spondylosis without myelopathy; lumbar radiculopathy; chondromalacia of the
patella; cervical neck disorder/symptoms, not otherwise specified; and lumbar
spine herniated nucleus pulposus.
On October 17, 2011, the claimant presented to Gary M. Weiss, M.D., with
headaches, neck and back pain secondary to a motor vehicle accident dated June
3, 2010. The claimant stated that months after the subject accident, she
experienced two different slip and falls, one on November 1, 2010, and again on
January 25, 2011. The fall on November 1, 2010, was recorded as the claimant
hitting her posterior head against an empty tub. She lost consciousness and was
taken to the hospital where she was admitted for 15 days. Her second accident
on January 25, 2011, noted that she rolled out of bed and hit her forehead and
chin against the night table. There was no loss of consciousness with this fall.
She was admitted to the hospital for four days. The claimant reported that she
had pain in the posterior cervical spine with radiation into both arms, right more
than left. There was numbness and tingling sensation, more left than right. She
had decreased range of motion with pain. Her thoracic spine revealed pain
radiating to the rib cage and chest with muscle spasm. There was constant pain
in the low back but did not radiate to the legs; denied numbness or tingling or
weakness. The claimant was noted to be alert and oriented x3. Gait and station
were normal including tandem, toe and heel walking. Romberg was negative.
Cranial nerves II through XII were intact. Reflexes, sensation, and muscle
strength were normal, symmetric and bilateral throughout. Cervical spine range
of motion showed minor reduction with spasms and tenderness. Foraminal
compression was deferred. Thoracic spine examinations revealed normal range of
motion with spasms. Lumbar spine range of motion was reduced with spasms.
The claimant was diagnosed with CHI with posttraumatic headaches and cognitive
loss; neck pain with some radicular symptoms; thoracic spine pain; low back pain
with radicular symptoms; and chronic pain with narcotic dependence.
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
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On January 10, 2012, the claimant returned to Dr. Weiss for a follow-up
examination. She reported that on December 12, 2011, she reported having pain
to her joints and stated she could not get out of bed without medication. She
disclosed that due to a severe anxiety attack with severe shortness of breath, she
was seen at HRMC. Her complaints at this visit were severe pain to the bilateral
thighs, knees, hips, and feet. Neurological and physical examination findings were
unchanged from the previous visit. She was diagnosed with CHI with
posttraumatic headaches and cognitive loss; neck pain with some radicular
symptoms; thoracic spine pain; low back pain with radicular symptoms; chronic
pain with narcotic dependence; new joint pain everywhere after infection. She
stated that on December 20, 2011, she started with a sore throat and then
developed mouth ulcers.
On September 6, 2012, the claimant presented to Srinivas Dontineni, M.D., at Palm
Bay Hospital. Her chief complaints were low back and neck pain. She stated she
had anxiety, panic attacks, migraines with a history of mitral valve prolapse, and
polycystic ovarian syndrome. It was noted she had a past medical history of a
motor vehicle accident in 2008 and a second accident in 2010. She was admitted
and given an epidural injection at an undisclosed spinal level. X-rays of the cervical
spine revealed no fracture or subluxation, mild accentuation of cervical lordosis.
X-ray of the lumbar spine revealed possible bilateral sclerotic L5 spondylosis. No
fractures or subluxations.
On September 10, 2012, an MRI of the lumbar spine was performed at Palm Bay
Hospital. The findings revealed the alignment was satisfactory. At L1-L2 through
L4-L5, the canal was well-maintained; the neuroforamina were patent. At L5-S1,
there was a broad-based focal disc protrusion central and to the left
posterolaterally with contiguity to the exiting nerve root off S1 and the level of the
foraminal exit with mild left foraminal compromise noted. The claimant was
discharged from Palm Bay Hospital on September 10, 2012, and referred to pain
management.
On July 2, 2013, an MRI of the cervical spine was performed at Weiss & Newberry
Medical Associates. The impression revealed abnormal MRI of the cervical spine
with herniated nucleus pulposus at C4-C5, C5-C6, and C6-C7.
On July 26, 2013, an x-ray of the right knee was performed at Health First Medical
Group. The impression revealed fibular exostosis, otherwise unremarkable study.
On November 9, 2013, the claimant presented to Syed B. Bhat, M.D., at Holmes
Family Medical Group. Chief complaints were knee pain, overweight, and back
pain. The claimant was noted to be 5 feet 5 inches tall and weighed 191 pounds.
Physical examination revealed that her gait and station were normal. Head and
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
Page 10
neck had normal alignment and mobility. She was neurologically intact. Her
general appearance was no acute distress, obese. Her assessment read
overweight, knee bursitis - right infrapatellar, and chronic pain syndrome.
On November 20, 2013, a CT scan of the cervical spine was performed at Palm
Bay Hospital. The impression revealed no fracture or acute-appearing bony
abnormality.
On November 20, 2013, x-rays of the lumbar spine were performed at Palm Bay
Hospital. These images were compared to a previous study dated September 10,
2012. The impression revealed lumbar vertebral body heights well preserved,
minimal degenerative changes at the lower thoracic spine, stable mild sclerotic
changes about L5 without anterolisthesis, and no suspicious bony lesions.
On February 26, 2014, an MRI of the brain was performed at Weiss & Newberry
Medical Associates. The impression revealed normal MRI of the brain with and
without paramagnetic contrast agent.
On March 17, 2014, the claimant presented to Devin Datta, M.D., at BACK
Authority for Contemporary Knowledge. She presented for a preoperative
evaluation and was scheduled to have oblique lumbar interbody fusion from L4 to
S1 with posterior instrumentation fusion with possibly Sextant versus open
procedure based on intraoperative findings. Physical examination revealed the
claimant ambulating with an upright stance, non-antalgic gait. She was able to
transfer independently. Strength in her lower extremities was mildly diminished
and she was able to walk on toes and heels. She had negative straight leg raise
bilaterally. Sensation was grossly intact and equal. The impression revealed disc
herniations L5-S1 to the left and L4-L5 to the right, back and right greater than
left leg pain.
On March 28, 2014, Dr. Datta performed an L4-S1 posterior spinal instrumented
fusion using Solera Sextant pedicle screw instrumentation; L4-L5 and L5-S1
oblique lateral interbody fusion (minimal invasive anterolateral retroperitoneal
exposure with placement of anterior interbody cages L4-L5 and L5-S1); L5-S1
anterior plate fixation; and left iliac crest bone marrow aspirate for concentration
of stem cells.
On April 29, 2014, the claimant returned to Dr. Weiss for a postoperative follow-
up evaluation. She reported that her headaches were not as severe since the
cervical epidurals. She stated she did have pain that did radiate down to her
shoulders, worse on the right. Physical examination findings were unchanged from
previous visits. The claimant was now status post lumbar surgery L4 through S1
by Dr. Datta, right greater than left shoulder pain. All other assessments were
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
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unchanged.
On August 15, 2014, Dr. Datta performed a C6-C7 Prestige disc replacement;
anterior cervical discectomy with decompression of posterior disc osteophyte
complexes, C6-C7.
On November 19, 2014, the claimant presented to S. Farhan Zaidi, M.D., at BACK
Authority for Contemporary Knowledge. The claimant stated she had neck and
low back pain, increased with activity. She reported that the pain radiated laterally
with intermittent numbness and tingling in the hands, low back pain radiating
towards bilateral buttocks, and numbness and tingling in the bilateral calves and
feet. The claimant had a history of lumbar and cervical spine surgeries. Physical
examination of the upper extremities showed functional range of motion in
bilateral upper extremities with gross strength within normal limits. Sensory was
grossly intact in the bilateral upper extremities, Hoffman’s sign was negative.
Deep tendon reflexes appeared symmetrical. Lower extremity evaluation revealed
functional range of motion; gross strength was within normal limits; and sensory
was intact bilaterally. Calves were soft and nontender. Gross strength was within
normal limits. Deep tendon reflexes appeared symmetrical. No Babinski was
elicited. Sitting root signs were negative. The assessment stated that the claimant
had a history of intermittent neck and low back pain with pain and dysesthesias
toward extremities. The claimant has had cervical and lumbar spine surgeries.
On January 27, 2015, the claimant returned to Dr. Weiss for a follow-up
examination. She reported that she was at physical therapy doing exercises as
directed and reinjured her neck and low back due to the ball coming out from
under her. She reported severe muscle spasms in her bilateral trapezius region,
stating when that happens, her hearing goes out. Her low back pain was constant
with radicular symptoms in her bilateral lower extremities. Neurological
examination was normal with gait and station including tandem, toe and heel
walking, and Romberg’s sign was negative. Reflexes were normal and symmetric
throughout. Sensation and motor were normal. The lumbar spine was restricted
with pain. Leg raise was positive bilaterally. Cervical spine revealed restricted
range of motion with pain and spasms. She was diagnosed with CHI with
posttraumatic headaches and cognitive loss; neck pain with some radicular
symptoms – herniated nucleus pulposus C4-C5, C5-C6 and C6-C7; thoracic spine
pain; status post lumbar spine surgery L4 through S1; chronic pain with narcotic
dependence; OSA/CSA suspected – EDS, nocturia, headaches, PLM, REM behavior
disorder; and right greater than left shoulder pain.
On February 2, 2015, an MRI of the cervical spine was performed at Weiss &
Newberry Medical Associates. The impression revealed normal MRI scan of the
cervical spine except for artifact at C6-C7, which obscured any visualization at that
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E
NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021
RE: Kelley Phillips
August 25, 2021
Page 12
level.
On July 29, 2015, the claimant presented to John J. Sassano, M.D., at Brevard
Orthopedic Spine and Pain Clinic, Inc. Her chief complaints were cervical, low
back, and upper back pain with headaches and right sciatic pain. Physical
examination of the cervical spine revealed tenderness to palpation with restricted
range of motion. Muscle strength was diminished in the upper extremities
bilaterally with decreased sensation. Lumbar spine evaluation revealed tenderness
to palpation over the sciatic nerve. She was diagnosed with prolapsed cervical
intervertebral disc, neck pain, low back pain, lumbar radiculopathy, cervical
radiculopathy, and thoracic or lumbosacral neuritis or radiculitis, unspecified.
On November 13, 2015, Dr. Datta performed C4-C5 and C5-C6 anterior cervical
discectomy and fusion using PEEK interbody cage, divergence cages, and
divergence anterior cervical plates with complete decompression of posterior
osteophyte complexes, right iliac crest bone marrow aspirate for concentrated
stem cells.
On April 14, 2016, a CT scan of lumbar spine was performed at NeuroSkeletal
Imaging. The impression revealed PO left pedicle screw and rod fusion spanning
L4 through S1, with interbody fusion at L4-L5 and L5-S1 including anterior plate
and screw fusion at L5-S1, new since prior study. There was a fracture involving
the mid aspect of the left S1 pedicle screw noted. At L4-L5, there were prominent
right paracentral foraminal end plate osteophytes new since the prior study, with
effacement of the right ventral thecal sac and right neuroforamen, with resulting
moderate right foraminal stenosis, new since the prior study. There was mild
bilateral facet arthropathy, although the central canal and left foramen are within
normal limits. The end plate osteophytes may just touch the right L4 nerve root
within the foramen and possibly touch the right descending L5 nerve root. At L5-
S1, there was no evidence of disc bulge or focal disc protrusion given prior findings.
There was mild bilateral facet arthropathy, although the central canal and
neuroforamen are within normal limits, with resolution of the previously noted left
foraminal stenosis. This study was compared to a CT scan of the lumbar spine
post discogram dated December 27, 2012.
On June 3, 2016, Dr. Datta removed the lumbar spinal hardware at L4 to S1.
On June 13, 2016, a CT scan of the cervical spine was performed at NeuroSkeletal
Imaging. The study was compared to a CT scan of the cervical spine post
discogram dated December 9, 2013. The impression revealed PO anterior and
interbody fusion spanning C4 through C7 since the prior study, including mild
improved disc space height at each of the cervical levels. At C4-C5, there was no
disc bulge or focal protrusion given prior appearance. The central spinal canal and
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neuroforamen is normal, stable. At C5-C6, there was no disc bulge or focal disc
protrusion given prior appearances. The central spinal canal and neuroforamen is
normal, stable. At C6-C7, streak artifact from intervertebral disc prosthesis limits
evaluation, particularly on the soft tissue windows. No definite disc bulge
identified. The central spinal canal and neuroforamen appear within normal limits.
On September 20, 2016, an x-ray of the lumbar spine was performed at
NeuroSkeletal Imaging. The impression revealed minimal levoscoliosis of the
thoracolumbar junction; PO interbody fusion at L4-L5 and L5-S1 including anterior
plate and screw fusion spanning L5-S1. No evidence of dynamic stability with
limited range of motion on flexion and extension maneuvers.
On September 20, 2016, Dr. Datta performed a cervical epidural steroid injection
at right C7-T1.
On October 4, 2016, Dr. Hicham Samir Merheb from Brevard Orthopedic Spine and
Pain Clinic, Inc., performed a cervical epidural steroid injection at C7-T1.
On October 12, 2016, an MRI of the lumbar spine was performed at Palm Bay
Hospital. The findings revealed interval placement of the anterior hardware at L4
through S1; visualized portions of the sacrum appeared intact; at T12-L4, the
thecal sac measures 12 mm or greater; neuroforamina appear patent; at L4-L5,
the thecal sac measures 12 mm at midline; right paracentral to far right lateral
broad-based protrusion along with endplate osteophyte which contributes to
asymmetric mild right foraminal stenosis; traversing right-sided nerve root is mildly
displaced; exiting right-sided nerve root also contacted; at L5-S1, thecal set
narrowing with overall AP diameter is 8 mm; foramen appear patent.
On October 19, 2016, Dr. Hicham Samir Merheb performed a lumbar epidural
steroid injection at L5-S1.
On December 20, 2016, an MRI of the thoracic spine was performed at First
Choice. The impression revealed at T5-T6, there was mild bilateral facet
arthropathy associated with mild dextrocurvature; at T6-T7, there was mild-to-
moderate focal disc herniation, effacing the right lateral recess; at T7-T8, there
was minimal disc herniation mildly effacing the ventral thecal sac; at T8-T9, there
was minimal disc herniation with annular fissure formation, mildly effacing the
ventral thecal sac; at T9-T10, there was minimal disc protrusion with annular
fissure formation, minimally effacing the ventral thecal sac; at T10-T11, there was
moderate disc herniation, moderately stenosing to the right neuroforamen; at T11-
T12, there was mild facet arthropathy; the canal remains patent throughout.
On February 27, 2017, the claimant presented to Dr. Datta for a follow-up
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examination. Her chief complaints were neck and low back pain. Physical
examination revealed the claimant was able to show functional range of motion in
the bilateral upper extremities. Gross strength, sensory, and deep tendon reflexes
were all normal. There was decreased end range of motion on shoulder flexion.
The lower extremities revealed functional range of motion with gross strength
throughout. Sensory was normal. No Babinski. Sitting root signs were negative.
There was discomfort on right knee range of motion. There was generalized
tenderness to palpation in the cervical and lumbar paraspinal muscles. The
claimant was diagnosed with other long-term (current) drug therapy, chronic low
back pain, chronic neck pain, and degeneration of the lumbar intervertebral disc.
On March 13, 2017, Dr. Datta performed a lumbar epidural steroid injection at L5-
S1.
On July 18, 2017, the claimant presented to Dr. Weiss for a follow-up examination.
She continued to complain of neck and low back pain. She stated she had
numbness and tingling constantly as well as cramping in her upper and lower
extremities. She complained of burning and tingling and numbness in her sacrum
as well as feet. Her feet were numb, and she was stumbling. She also reported
four migraine headaches within the past six days. Physical examination revealed
gait and station affected including tandem, toe and heel walking; stumbled with
toe and heel walking. Cranial nerves II through XII were intact. Strength in all
four extremities was within normal limits. There was no evidence of atrophy or
fasciculations. Reflexes were normal throughout. Sensation was decreased in the
bilateral lower extremities, more so in the feet. Cervical and lumbar spine range
of motion was restricted with tenderness. Straight leg test was positive bilaterally.
She was diagnosed with CHI with posttraumatic headaches and cognitive loss;
Aricept was of no help - possible concentration problems as well, amnesia short
term; neck pain with some radicular symptoms - herniated nucleus pulposus at
C4-C5, C5-C6 and C6-C7 – status post surgery x2 - last one in November of 2015;
thoracic spine pain; status post lumbar spine surgeries, L4 through S1, March 28,
2014 and June 2016, both by Dr. Datta; chronic pain with narcotic dependence;
OSA/CSA suspected - EDS, nocturia, headaches, PLM, REM behavior disorder. Her
non-motor vehicle accident related diagnosis was some short-term memory issues
with motor vehicle accident before the CHI, but she reports these were much
milder prior to CHI. Her diagnoses were status post right knee surgery on
September 20, 2013; elevated liver enzymes – now stable; occipital neuralgia;
generalized anxiety disorder - not controlled with panic attacks; major depressive
disorder - in remission; migraines, debilitating with aura; decreased sensation to
bilateral lower extremities; and dependence on narcotic pain meds.
On August 29, 2017, an MRI of the cervical spine was performed at Palm Bay
Hospital. The impression revealed markedly limited examination of the cervical
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spine due to metallic susceptibility artifact from anterior cervical fusion hardware.
The visualized portions of the upper cervical and upper thoracic cord are within
normal limits.
On August 30, 2017, a CT scan of the cervical spine was performed at Palm Bay
Hospital. The impression revealed status post anterior cervical discectomy and
fusion spanning C4 through C7 as described above without evidence of hardware
loosening or failure. The canal and neuroforamina appear patent. Limited
evaluation of the thecal sac contents shows no gross abnormalities.
On September 16, 2017, x-rays of the thoracic and lumbar spines were performed
at Palm Bay Hospital. The impression stated degenerative and postsurgical
changes, no acute fracture. These studies were compared to x-rays dated March
28, 2014, and a CT scan dated July 3, 2016.
On September 26, 2017, an MRI of the thoracic spine was performed at Weiss &
Newberry Medical Associates. The impression stated normal MRI scan of the
thoracic spine.
On September 26, 2017, an MRI of the cervical spine was performed at Weiss &
Newberry Medical Associates. The impression stated normal MRI scan of the
cervical spine except for postop changes starting at C4 and going caudally with
artifact at C6-C7.
On September 27, 2017, an MRI of the brain was performed at Weiss & Newberry
Medical Associates. This study was compared to previous images performed on
February 26, 2014. The impression revealed mildly abnormal MRI of the brain
with and without paramagnetic contrast agent with periventricular changes
maximum at the anterior horns bilaterally and two additional small white matter
lesions on FLAIR which are nonspecific in etiology.
On October 9, 2017, an MRI of the lumbar spine
Preview
FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 EXHIBIT AA FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 Sports & Entertainment Physicians, P.C. Andrew N. Bazos, M.D. Diplomate, American Board of Orthopedic Surgery August 25, 2021 Ms. Yacine Williams, Paralegal Kiernan & Trebach 40 Exchange Place, Suite 1600 New York, NY 10005 Email: ywilliams@kiernantrebach.com CLAIMANT: Kelley Phillips DATE OF LOSS: June 3, 2010 FILE NUMBER: 1978.0009 INDEPENDENT MEDICAL RECORD REVIEW and EXAMINATION To Whom It May Concern: PURPOSE: At your request, I performed an independent medical record review and examination (08/19/21) of the claimant, Kelley Phillips, and injuries she allegedly sustained in an accident dated June 3, 2010. REVIEW OF MEDICAL RECORDS: In forming my opinions, I relied upon the following medical records: 1. Verified Bill of Particulars dated March 27, 2014. 2. Supplemental verified Bill of Particulars dated April 27, 2014. 3. Supplemental verified Bill of Particulars dated October 17, 2014. 4. Supplemental verified Bill of Particulars dated April 24, 2015. 5. Supplemental verified Bill of Particulars dated May 19, 2021. 6. X-ray of the pelvis report from Montefiore Hospital dated June 30, 2010. 7. X-ray of the lumbar spine report from Montefiore Hospital dated June 30, 2010. 8. X-ray of the cervical spine report from Montefiore Hospital dated June 30, 2010. 9. MRI of the lumbar spine report for Montefiore Hospital dated July 2, 2010. 10.MRI of the cervical spine report from Montefiore Hospital dated July 7, 2010. 11.Memo from Ashley Moloney, PA-C, dated August 20, 2010. 12.Medical records from Sireen Gopal, M.D., dated September 28, 2010, through July 28, 2011. FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 2 13.Operative report regarding lumbar paravertebral facet joint injections by Sireen Gopal, M.D., dated October 20, 2010. 14.CT scan of the cervical spine report from Montefiore Hospital dated November 1, 2010. 15.CT scan of the head report from Montefiore Hospital dated November 1, 2010. 16.MRI of the brain report from Montefiore Hospital dated November 3, 2010. 17.MRI of the lumbar spine report from Montefiore Hospital dated November 3, 2010. 18.MRI of the cervical spine report from Montefiore Hospital dated November 3, 2010. 19.Operative report of a lumbar epidural steroid injection by Sireen Gopal, M.D., dated November 17, 2010. 20.Operative report regarding transforaminal lumbar epidural steroid injection by Sireen Gopal, M.D., dated December 1, 2010. 21.CT scan of the cervical spine report from Montefiore Hospital dated January 22, 2011. 22.CT scan of the head report from Montefiore Hospital dated January 27, 2011. 23.X-ray of the right knee report from New York Spine and Sport Rehabilitation Medicine, P.C., dated March 8, 2011. 24.Operative report regarding cervical facet joint medial branch block/injection by Sireen Gopal, MD, dated April 14, 2011. 25.Operative report regarding cervical/thoracic facet joint injection by Sireen Gopal, M.D., dated May 24, 2011. 26.Medical records from Health First Medical Group dated June 1, 2011, through February 7, 2014. 27.MRI of the cervical spine report from Palm Bay Hospital dated July 23, 2011. 28.Medical records from Lynette M. Graff, M.D., dated September 26, 2011, through November 29, 2012. 29.Letter from Kelley Phillips, M.D., to Maria Svark dated October 27, 2010. 30.Operative report regarding cervical facet joint medial branch block/injection by Sireen Gopal, M.D., dated March 2, 2011. 31.Medical records from Gary Weiss, M.D., dated October 17, 2011, through July 20, 2020. 32.Medical records from Laurel McHone, MS, dated March 15, 2012, through May 12, 2014. 33.Medical records from Palm County Community Hospital Emergency Department dated July 13, 2012. 34.Ultrasound of the abdomen report from Health First Medical Group dated August 29, 2012. 35.Medical records from Palm Bay Hospital dated September 6, 2012, through September 10, 2012. 36.X-ray of the cervical spine report from Palm Bay Hospital dated September 10, 2012. FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 3 37.X-ray of the lumbar spine report from Palm Bay Hospital dated September 10, 2012. 38.MRI of the lumbar spine report from Palm Bay Hospital dated September 10, 2012. 39.Medical records from Scott Z. Seminer, M.D., dated January 8, 2013, through February 5, 2013. 40.MRI of the cervical spine report from Weiss & Newberry Medical Associates dated July 2, 2013. 41.X-ray of the right knee report from Health First Medical Group dated July 26, 2013. 42.Ultrasound of the abdomen report from Atlantis Diagnostics dated January 15, 2013. 43.CT scan of the cervical spine report from Palm Bay Hospital dated November 20, 2013. 44.X-ray of the lumbar spine report from Palm Bay Hospital dated November 20, 2013. 45.Chest x-ray report from Health First Medical Group dated December 27, 2013. 46.MRI of the brain report from Weiss & Newberry Medical Associates dated February 26, 2014. 47.Medical records from BACK Authority for Contemporary Knowledge dated March 17, 2014, through July 1, 2015. 48.Operative report regarding lumbar fusion at L4-L5 and L5-S1 by Devin Datta, M.D., dated March 28, 2014. 49.Operative report regarding C6-C7 disc replacement by Devin Datta, M.D., dated August 15, 2014. 50.MRI of the cervical spine report by Weiss & Newberry Medical Associates dated February 2, 2015. 51.Medical records from Brevard Orthopaedic Spine and Pain Clinic, Inc., dated July 29, 2015, through March 13, 2017. 52.Operative report regarding anterior cervical discectomy and fusion at C4-C5 and C5-C6 by Devin Datta, M.D., dated November 13, 2015. 53.CT scan of the lumbar spine report by NeuroSkeletal Imaging dated April 14, 2016. 54.Operative report regarding removal of lumbar hardware by Devin Datta, M.D., dated June 3, 2016. 55.CT scan of the cervical spine report by NeuroSkeletal Imaging dated June 13, 2016. 56.CT angio of the thorax from Palm Bay Hospital dated July 3, 2016. 57.Chest x-ray report from Palm Bay Hospital dated July 3, 2016. 58.X-ray of the lumbar spine report from NeuroSkeletal Imaging dated September 20, 2016. 59.Operative report regarding cervical epidural steroid injection by Devin Datta, M.D. dated September 20, 2016. FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 4 60.Chest x-ray report from Palm Bay Hospital dated September 26, 2016. 61.Chest x-ray report from Palm Bay Hospital dated October 1, 2016. 62.Operative report regarding cervical epidural steroid injection by Hicham Samir Merheb, M.D. dated October 4, 2016. 63.MRI of the lumbar spine report from Palm Bay Hospital dated October 12, 2016. 64.Operative report regarding lumbar epidural steroid injection at L5-S1 by Hicham Samir Merheb, M.D., dated October 19, 2016. 65.CT scan of the head report from Palm Bay Hospital dated October 25, 2016. 66.MRI of the thoracic spine report from First Choice dated December 20, 2016. 67.Operative report regarding lumbar epidural steroid injection at L5-S1 by Devin Datta, M.D., dated March 13, 2017. 68.X-ray of the lumbar spine report from Palm Bay Hospital dated August 27, 2017. 69.MRI of the cervical spine report from Palm Bay Hospital dated August 29, 2017. 70.MRI of the brain report from Palm Bay Hospital dated August 29, 2017. 71.CT scan of the cervical spine report from Palm Bay Hospital dated August 30, 2017. 72.X-ray of the thoracic and lumbar spine report from Palm Bay Hospital dated September 16, 2017. 73.MRI of the thoracic spine report from Weiss & Newberry Medical Associates dated September 26, 2017. 74.MRI of the cervical spine report from Weiss & Newberry Medical Associates dated September 26, 2017. 75.MRI of the brain report from Weiss & Newberry Medical Associates dated September 27, 2017. 76.MRI of the lumbar spine report from Weiss & Newberry Medical Associates dated October 10, 2017. 77.Fluoroscopically guided lumbar spine puncture report from Palm Bay Hospital dated November 9, 2017. 78.MRI of the brain report from Weiss & Newberry Medical Associates dated January 16, 2018. 79.MRI of the brain report from Weiss & Newberry Medical Associates dated May 10, 2018. 80.MRI of the cerebrals report from Weiss & Newberry Medical Associates dated May 15, 2018. 81.MRA of the carotids report from Weiss & Newberry Medical Associates dated May 15, 2018. 82.Operative report regarding placement of spinal or similar generator left flank by Devin Datta, M.D., dated June 29, 2018. 83.MRI of the cervical spine report from Weiss & Newberry Medical Associates dated January 15, 2019. 84.MRI of the lumbar spine report from Weiss & Newberry Medical Associates dated January 22, 2019. FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 5 85.MRI of the brain report from Weiss & Newberry Medical Associates dated January 4, 2019. 86.Operative report regarding lumbar and cervical epidural steroid injections by Devin Datta, M.D., dated August 2, 2019. 87.Medical records from Montefiore Medical Center dated February 1, 2009, through March 26, 2010. 88.MRI of the cervical spine report from Montefiore Hospital dated April 7, 2010. 89.MRI of the brachial plexus, right side report from Advanced Imaging - Gun Hill Road dated April 8, 2010. 90.MRI of the cervical spine report from Advanced Imaging - Gun Hill Road dated April 8, 2010. 91.Deposition of Kelley Phillips dated November 18, 2011. 92.Deposition of Kelley Phillips dated July 27, 2016. HISTORY: The claimant is a 31-year-old female who, on June 30, 2010, had x-rays of the pelvis, lumbar spine, and cervical spine performed at Montefiore Hospital. Both studies of the pelvis and lumbar spine revealed no acute fracture, dislocation, or subluxation. The cervical spine revealed minimal grade 1 retrolisthesis of C4 on C5. She had an unremarkable examination of the dorsal spine. On July 2, 2010, an MRI of the lumbar spine was performed at Montefiore Hospital. The impression revealed small and left paracentral disc protrusion at L5-S1. No central or foraminal impingement. On July 7, 2010, an MRI of the cervical spine was performed at Montefiore Hospital. The impression revealed unremarkable examination of the cervical spine. On August 20, 2010, a pain management appointment request from Ashley Moloney, PA-C, stated that the claimant was a 32-year-old female with a history of a motor vehicle accident in December of 2008 and June of 2010, who has a history of chronic back pain. On September 28, 2010, the claimant presented to Sireen Gopal, M.D., with chief complaints of neck pain, lower extremity pain, and back pain. The claimant stated she had pain in her neck area radiating down into the bilateral posterior shoulders and pain in the lower back. The claimant’s past medical history was positive for anxiety disorder, migraine headache, and motor vehicle accident. Physical examination of the lumbar spine revealed restricted range of motion, trigger points, and pain. Straight leg raise and Fabere tests were negative bilaterally. Deep tendon reflexes, muscle strength, and sensory were all normal. Cervical spine examination revealed limited range of motion, myofascial trigger points, and FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 6 Spurling’s, Babinski and Hoffman’s tests were all negative. Upper back evaluation revealed myofascial trigger points bilaterally. The claimant was diagnosed with lumbar spine herniated nucleus pulposus; backache, not otherwise specified; cervical neck disorders/symptoms; unspecified myalgia and myositis. On September 30, 2010, the claimant returned to Dr. Gopal’s office for an initial physical therapy evaluation. Her working diagnoses were lumbar spine herniated nucleus pulposus; backache, not otherwise specified; cervical - neck disorder/symptoms; and unspecified myalgia and myositis. On October 20, 2010, Dr. Gopal performed lumbar paravertebral facet and joint injections at L3-L4, L4-L5 and L5-S1, left-sided. On November 1, 2010, Dr. Gopal performed a transforaminal lumbar epidural steroid joint injection. No levels were disclosed. On November 1, 2010, a CT scan of the head was performed at Montefiore Hospital. The impression revealed normal non-contrast CT of the brain. On November 1, 2010, a CT scan of the cervical spine was performed at Montefiore Hospital. The impression stated that prominent soft tissue along the posterior margin of the odontoid process may represent underlying soft tissue or ligamentous injury. No discrete fracture. If symptoms persist, an MRI of the cervical spine was recommended to evaluate for soft tissue and/or ligamentous injury; normal atlantoaxial interval. On November 3, 2010, an MRI of the brain was performed at Montefiore Hospital. The impression stated unremarkable enhanced MRI of the brain. On November 3, 2010, an MRI of the lumbar spine was performed at Montefiore Hospital. The impression stated that at L5-S1, there was an asymmetric disc bulge to the left causing compression of the left S1 nerve root. On November 3, 2010, an MRI of the cervical spine was performed at Montefiore Hospital. The impression stated that there was no acute fracture or dislocation. Mild disc bulges were noted at C4-C5 through C6-C7. On November 17, 2010, the claimant presented to Amy Phillips, PA, at the office of Sireen Gopal, M.D., for a follow-up appointment after hospitalization. The claimant was noted to have just been discharged from the hospital status post slip-and-fall in her bathroom. She remained in the hospital from November 1, 2010, through November 16, 2010 for postconcussive syndrome, nausea and vomiting. Physical examination revealed tenderness in the bilateral lumbar facets FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 7 with trigger points. Lumbar range of motion was limited. Straight leg raising and Patrick/Fabere test was negative bilaterally. Bilateral upper and lower extremities revealed normal strength, sensory, and deep tendon reflexes. Babinski was negative. The claimant was diagnosed with cervical - neck disorder/symptoms, not otherwise specified; lumbar spine herniated nucleus pulposus; unspecified myalgia and myositis; and lumbar radiculopathy. A transforaminal lumbar epidural steroid injection was performed. On December 1, 2010, Dr. Gopal performed a transforaminal lumbar epidural steroid injection at L5 and S1. On January 27, 2011, a CT scan of the cervical spine was performed at Montefiore Hospital. The impression stated there was no evidence of acute fracture or subluxation, no intracranial hemorrhage. On March 2, 2011, Dr. Gopal performed a cervical facet joint medial branch block/injection at C3, C4, and C5. On March 8, 2011, x-rays of the right knee were performed at New York Spine and Sports Rehabilitation Medicine, P.C. The impression revealed no acute fracture. On March 21, 2011, the claimant returned to Dr. Gopal for a follow-up examination. All chief complaints, physical examination findings, and diagnoses were unchanged with the exception of right knee pain. The examination revealed limited range of motion and tenderness on the right medial joint line. The claimant was diagnosed with cervical - neck disorder/symptoms, not otherwise specified; backache, not otherwise specified; cervical spondylosis without myelopathy; chondromalacia of the patella; lumbar spine herniated nucleus pulposus; and unspecified myalgia and myositis. Trigger point injections were performed in an undisclosed location. On April 14, 2011, Dr. Gopal performed a cervical facet joint medial branch block/injection at left-sided C2, C3, and C4. On May 24, 2011, Dr. Gopal performed a cervical/thoracic facet joint injection. On June 1, 2011, the claimant presented to Joe O. Littlejohn, M.D., at Holmes Family Medical Group with a chief complaint of urinary retention. The only significance to this file is the disclosure of the claimant stating that she had two previous head traumas after drinking alcohol while on a muscle relaxant, passing out and hitting her head. On July 23, 2011, an MRI of the cervical spine was performed at Holmes Regional Medical Center. The impression revealed multilevel mild disc bulges as discussed FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 8 without significant change from prior study. On July 8, 2011, the claimant presented to Amy Phillips, PA, at New York Spine and Sports Rehabilitation Medicine, P.C. The claimant was there for a follow-up, complaining of pain in the neck radiating into the bilateral posterior shoulders with numbness in the left medial forearm and upper middle back and pain in the low back with non-radiation. Physical examination revealed the claimant was alert and oriented x3. Her gait was normal, no edema or skin lesions. Physical examination of the cervical, thoracic, and lumbar spine revealed restricted range of motion with tenderness to palpation and spasms. Deep tendon reflexes were equal, symmetrical, and bilateral. Examination of the right knee revealed limited range of motion, no swelling or redness. There was tenderness to palpation along the lateral joint line. Grind test was positive. She was diagnosed with cervical spondylosis without myelopathy; lumbar radiculopathy; chondromalacia of the patella; cervical neck disorder/symptoms, not otherwise specified; and lumbar spine herniated nucleus pulposus. On October 17, 2011, the claimant presented to Gary M. Weiss, M.D., with headaches, neck and back pain secondary to a motor vehicle accident dated June 3, 2010. The claimant stated that months after the subject accident, she experienced two different slip and falls, one on November 1, 2010, and again on January 25, 2011. The fall on November 1, 2010, was recorded as the claimant hitting her posterior head against an empty tub. She lost consciousness and was taken to the hospital where she was admitted for 15 days. Her second accident on January 25, 2011, noted that she rolled out of bed and hit her forehead and chin against the night table. There was no loss of consciousness with this fall. She was admitted to the hospital for four days. The claimant reported that she had pain in the posterior cervical spine with radiation into both arms, right more than left. There was numbness and tingling sensation, more left than right. She had decreased range of motion with pain. Her thoracic spine revealed pain radiating to the rib cage and chest with muscle spasm. There was constant pain in the low back but did not radiate to the legs; denied numbness or tingling or weakness. The claimant was noted to be alert and oriented x3. Gait and station were normal including tandem, toe and heel walking. Romberg was negative. Cranial nerves II through XII were intact. Reflexes, sensation, and muscle strength were normal, symmetric and bilateral throughout. Cervical spine range of motion showed minor reduction with spasms and tenderness. Foraminal compression was deferred. Thoracic spine examinations revealed normal range of motion with spasms. Lumbar spine range of motion was reduced with spasms. The claimant was diagnosed with CHI with posttraumatic headaches and cognitive loss; neck pain with some radicular symptoms; thoracic spine pain; low back pain with radicular symptoms; and chronic pain with narcotic dependence. FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 9 On January 10, 2012, the claimant returned to Dr. Weiss for a follow-up examination. She reported that on December 12, 2011, she reported having pain to her joints and stated she could not get out of bed without medication. She disclosed that due to a severe anxiety attack with severe shortness of breath, she was seen at HRMC. Her complaints at this visit were severe pain to the bilateral thighs, knees, hips, and feet. Neurological and physical examination findings were unchanged from the previous visit. She was diagnosed with CHI with posttraumatic headaches and cognitive loss; neck pain with some radicular symptoms; thoracic spine pain; low back pain with radicular symptoms; chronic pain with narcotic dependence; new joint pain everywhere after infection. She stated that on December 20, 2011, she started with a sore throat and then developed mouth ulcers. On September 6, 2012, the claimant presented to Srinivas Dontineni, M.D., at Palm Bay Hospital. Her chief complaints were low back and neck pain. She stated she had anxiety, panic attacks, migraines with a history of mitral valve prolapse, and polycystic ovarian syndrome. It was noted she had a past medical history of a motor vehicle accident in 2008 and a second accident in 2010. She was admitted and given an epidural injection at an undisclosed spinal level. X-rays of the cervical spine revealed no fracture or subluxation, mild accentuation of cervical lordosis. X-ray of the lumbar spine revealed possible bilateral sclerotic L5 spondylosis. No fractures or subluxations. On September 10, 2012, an MRI of the lumbar spine was performed at Palm Bay Hospital. The findings revealed the alignment was satisfactory. At L1-L2 through L4-L5, the canal was well-maintained; the neuroforamina were patent. At L5-S1, there was a broad-based focal disc protrusion central and to the left posterolaterally with contiguity to the exiting nerve root off S1 and the level of the foraminal exit with mild left foraminal compromise noted. The claimant was discharged from Palm Bay Hospital on September 10, 2012, and referred to pain management. On July 2, 2013, an MRI of the cervical spine was performed at Weiss & Newberry Medical Associates. The impression revealed abnormal MRI of the cervical spine with herniated nucleus pulposus at C4-C5, C5-C6, and C6-C7. On July 26, 2013, an x-ray of the right knee was performed at Health First Medical Group. The impression revealed fibular exostosis, otherwise unremarkable study. On November 9, 2013, the claimant presented to Syed B. Bhat, M.D., at Holmes Family Medical Group. Chief complaints were knee pain, overweight, and back pain. The claimant was noted to be 5 feet 5 inches tall and weighed 191 pounds. Physical examination revealed that her gait and station were normal. Head and FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 10 neck had normal alignment and mobility. She was neurologically intact. Her general appearance was no acute distress, obese. Her assessment read overweight, knee bursitis - right infrapatellar, and chronic pain syndrome. On November 20, 2013, a CT scan of the cervical spine was performed at Palm Bay Hospital. The impression revealed no fracture or acute-appearing bony abnormality. On November 20, 2013, x-rays of the lumbar spine were performed at Palm Bay Hospital. These images were compared to a previous study dated September 10, 2012. The impression revealed lumbar vertebral body heights well preserved, minimal degenerative changes at the lower thoracic spine, stable mild sclerotic changes about L5 without anterolisthesis, and no suspicious bony lesions. On February 26, 2014, an MRI of the brain was performed at Weiss & Newberry Medical Associates. The impression revealed normal MRI of the brain with and without paramagnetic contrast agent. On March 17, 2014, the claimant presented to Devin Datta, M.D., at BACK Authority for Contemporary Knowledge. She presented for a preoperative evaluation and was scheduled to have oblique lumbar interbody fusion from L4 to S1 with posterior instrumentation fusion with possibly Sextant versus open procedure based on intraoperative findings. Physical examination revealed the claimant ambulating with an upright stance, non-antalgic gait. She was able to transfer independently. Strength in her lower extremities was mildly diminished and she was able to walk on toes and heels. She had negative straight leg raise bilaterally. Sensation was grossly intact and equal. The impression revealed disc herniations L5-S1 to the left and L4-L5 to the right, back and right greater than left leg pain. On March 28, 2014, Dr. Datta performed an L4-S1 posterior spinal instrumented fusion using Solera Sextant pedicle screw instrumentation; L4-L5 and L5-S1 oblique lateral interbody fusion (minimal invasive anterolateral retroperitoneal exposure with placement of anterior interbody cages L4-L5 and L5-S1); L5-S1 anterior plate fixation; and left iliac crest bone marrow aspirate for concentration of stem cells. On April 29, 2014, the claimant returned to Dr. Weiss for a postoperative follow- up evaluation. She reported that her headaches were not as severe since the cervical epidurals. She stated she did have pain that did radiate down to her shoulders, worse on the right. Physical examination findings were unchanged from previous visits. The claimant was now status post lumbar surgery L4 through S1 by Dr. Datta, right greater than left shoulder pain. All other assessments were FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 11 unchanged. On August 15, 2014, Dr. Datta performed a C6-C7 Prestige disc replacement; anterior cervical discectomy with decompression of posterior disc osteophyte complexes, C6-C7. On November 19, 2014, the claimant presented to S. Farhan Zaidi, M.D., at BACK Authority for Contemporary Knowledge. The claimant stated she had neck and low back pain, increased with activity. She reported that the pain radiated laterally with intermittent numbness and tingling in the hands, low back pain radiating towards bilateral buttocks, and numbness and tingling in the bilateral calves and feet. The claimant had a history of lumbar and cervical spine surgeries. Physical examination of the upper extremities showed functional range of motion in bilateral upper extremities with gross strength within normal limits. Sensory was grossly intact in the bilateral upper extremities, Hoffman’s sign was negative. Deep tendon reflexes appeared symmetrical. Lower extremity evaluation revealed functional range of motion; gross strength was within normal limits; and sensory was intact bilaterally. Calves were soft and nontender. Gross strength was within normal limits. Deep tendon reflexes appeared symmetrical. No Babinski was elicited. Sitting root signs were negative. The assessment stated that the claimant had a history of intermittent neck and low back pain with pain and dysesthesias toward extremities. The claimant has had cervical and lumbar spine surgeries. On January 27, 2015, the claimant returned to Dr. Weiss for a follow-up examination. She reported that she was at physical therapy doing exercises as directed and reinjured her neck and low back due to the ball coming out from under her. She reported severe muscle spasms in her bilateral trapezius region, stating when that happens, her hearing goes out. Her low back pain was constant with radicular symptoms in her bilateral lower extremities. Neurological examination was normal with gait and station including tandem, toe and heel walking, and Romberg’s sign was negative. Reflexes were normal and symmetric throughout. Sensation and motor were normal. The lumbar spine was restricted with pain. Leg raise was positive bilaterally. Cervical spine revealed restricted range of motion with pain and spasms. She was diagnosed with CHI with posttraumatic headaches and cognitive loss; neck pain with some radicular symptoms – herniated nucleus pulposus C4-C5, C5-C6 and C6-C7; thoracic spine pain; status post lumbar spine surgery L4 through S1; chronic pain with narcotic dependence; OSA/CSA suspected – EDS, nocturia, headaches, PLM, REM behavior disorder; and right greater than left shoulder pain. On February 2, 2015, an MRI of the cervical spine was performed at Weiss & Newberry Medical Associates. The impression revealed normal MRI scan of the cervical spine except for artifact at C6-C7, which obscured any visualization at that FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 12 level. On July 29, 2015, the claimant presented to John J. Sassano, M.D., at Brevard Orthopedic Spine and Pain Clinic, Inc. Her chief complaints were cervical, low back, and upper back pain with headaches and right sciatic pain. Physical examination of the cervical spine revealed tenderness to palpation with restricted range of motion. Muscle strength was diminished in the upper extremities bilaterally with decreased sensation. Lumbar spine evaluation revealed tenderness to palpation over the sciatic nerve. She was diagnosed with prolapsed cervical intervertebral disc, neck pain, low back pain, lumbar radiculopathy, cervical radiculopathy, and thoracic or lumbosacral neuritis or radiculitis, unspecified. On November 13, 2015, Dr. Datta performed C4-C5 and C5-C6 anterior cervical discectomy and fusion using PEEK interbody cage, divergence cages, and divergence anterior cervical plates with complete decompression of posterior osteophyte complexes, right iliac crest bone marrow aspirate for concentrated stem cells. On April 14, 2016, a CT scan of lumbar spine was performed at NeuroSkeletal Imaging. The impression revealed PO left pedicle screw and rod fusion spanning L4 through S1, with interbody fusion at L4-L5 and L5-S1 including anterior plate and screw fusion at L5-S1, new since prior study. There was a fracture involving the mid aspect of the left S1 pedicle screw noted. At L4-L5, there were prominent right paracentral foraminal end plate osteophytes new since the prior study, with effacement of the right ventral thecal sac and right neuroforamen, with resulting moderate right foraminal stenosis, new since the prior study. There was mild bilateral facet arthropathy, although the central canal and left foramen are within normal limits. The end plate osteophytes may just touch the right L4 nerve root within the foramen and possibly touch the right descending L5 nerve root. At L5- S1, there was no evidence of disc bulge or focal disc protrusion given prior findings. There was mild bilateral facet arthropathy, although the central canal and neuroforamen are within normal limits, with resolution of the previously noted left foraminal stenosis. This study was compared to a CT scan of the lumbar spine post discogram dated December 27, 2012. On June 3, 2016, Dr. Datta removed the lumbar spinal hardware at L4 to S1. On June 13, 2016, a CT scan of the cervical spine was performed at NeuroSkeletal Imaging. The study was compared to a CT scan of the cervical spine post discogram dated December 9, 2013. The impression revealed PO anterior and interbody fusion spanning C4 through C7 since the prior study, including mild improved disc space height at each of the cervical levels. At C4-C5, there was no disc bulge or focal protrusion given prior appearance. The central spinal canal and FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 13 neuroforamen is normal, stable. At C5-C6, there was no disc bulge or focal disc protrusion given prior appearances. The central spinal canal and neuroforamen is normal, stable. At C6-C7, streak artifact from intervertebral disc prosthesis limits evaluation, particularly on the soft tissue windows. No definite disc bulge identified. The central spinal canal and neuroforamen appear within normal limits. On September 20, 2016, an x-ray of the lumbar spine was performed at NeuroSkeletal Imaging. The impression revealed minimal levoscoliosis of the thoracolumbar junction; PO interbody fusion at L4-L5 and L5-S1 including anterior plate and screw fusion spanning L5-S1. No evidence of dynamic stability with limited range of motion on flexion and extension maneuvers. On September 20, 2016, Dr. Datta performed a cervical epidural steroid injection at right C7-T1. On October 4, 2016, Dr. Hicham Samir Merheb from Brevard Orthopedic Spine and Pain Clinic, Inc., performed a cervical epidural steroid injection at C7-T1. On October 12, 2016, an MRI of the lumbar spine was performed at Palm Bay Hospital. The findings revealed interval placement of the anterior hardware at L4 through S1; visualized portions of the sacrum appeared intact; at T12-L4, the thecal sac measures 12 mm or greater; neuroforamina appear patent; at L4-L5, the thecal sac measures 12 mm at midline; right paracentral to far right lateral broad-based protrusion along with endplate osteophyte which contributes to asymmetric mild right foraminal stenosis; traversing right-sided nerve root is mildly displaced; exiting right-sided nerve root also contacted; at L5-S1, thecal set narrowing with overall AP diameter is 8 mm; foramen appear patent. On October 19, 2016, Dr. Hicham Samir Merheb performed a lumbar epidural steroid injection at L5-S1. On December 20, 2016, an MRI of the thoracic spine was performed at First Choice. The impression revealed at T5-T6, there was mild bilateral facet arthropathy associated with mild dextrocurvature; at T6-T7, there was mild-to- moderate focal disc herniation, effacing the right lateral recess; at T7-T8, there was minimal disc herniation mildly effacing the ventral thecal sac; at T8-T9, there was minimal disc herniation with annular fissure formation, mildly effacing the ventral thecal sac; at T9-T10, there was minimal disc protrusion with annular fissure formation, minimally effacing the ventral thecal sac; at T10-T11, there was moderate disc herniation, moderately stenosing to the right neuroforamen; at T11- T12, there was mild facet arthropathy; the canal remains patent throughout. On February 27, 2017, the claimant presented to Dr. Datta for a follow-up FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 14 examination. Her chief complaints were neck and low back pain. Physical examination revealed the claimant was able to show functional range of motion in the bilateral upper extremities. Gross strength, sensory, and deep tendon reflexes were all normal. There was decreased end range of motion on shoulder flexion. The lower extremities revealed functional range of motion with gross strength throughout. Sensory was normal. No Babinski. Sitting root signs were negative. There was discomfort on right knee range of motion. There was generalized tenderness to palpation in the cervical and lumbar paraspinal muscles. The claimant was diagnosed with other long-term (current) drug therapy, chronic low back pain, chronic neck pain, and degeneration of the lumbar intervertebral disc. On March 13, 2017, Dr. Datta performed a lumbar epidural steroid injection at L5- S1. On July 18, 2017, the claimant presented to Dr. Weiss for a follow-up examination. She continued to complain of neck and low back pain. She stated she had numbness and tingling constantly as well as cramping in her upper and lower extremities. She complained of burning and tingling and numbness in her sacrum as well as feet. Her feet were numb, and she was stumbling. She also reported four migraine headaches within the past six days. Physical examination revealed gait and station affected including tandem, toe and heel walking; stumbled with toe and heel walking. Cranial nerves II through XII were intact. Strength in all four extremities was within normal limits. There was no evidence of atrophy or fasciculations. Reflexes were normal throughout. Sensation was decreased in the bilateral lower extremities, more so in the feet. Cervical and lumbar spine range of motion was restricted with tenderness. Straight leg test was positive bilaterally. She was diagnosed with CHI with posttraumatic headaches and cognitive loss; Aricept was of no help - possible concentration problems as well, amnesia short term; neck pain with some radicular symptoms - herniated nucleus pulposus at C4-C5, C5-C6 and C6-C7 – status post surgery x2 - last one in November of 2015; thoracic spine pain; status post lumbar spine surgeries, L4 through S1, March 28, 2014 and June 2016, both by Dr. Datta; chronic pain with narcotic dependence; OSA/CSA suspected - EDS, nocturia, headaches, PLM, REM behavior disorder. Her non-motor vehicle accident related diagnosis was some short-term memory issues with motor vehicle accident before the CHI, but she reports these were much milder prior to CHI. Her diagnoses were status post right knee surgery on September 20, 2013; elevated liver enzymes – now stable; occipital neuralgia; generalized anxiety disorder - not controlled with panic attacks; major depressive disorder - in remission; migraines, debilitating with aura; decreased sensation to bilateral lower extremities; and dependence on narcotic pain meds. On August 29, 2017, an MRI of the cervical spine was performed at Palm Bay Hospital. The impression revealed markedly limited examination of the cervical FILED: BRONX COUNTY CLERK 10/25/2021 10:40 PM INDEX NO. 21169/2011E NYSCEF DOC. NO. 238 RECEIVED NYSCEF: 10/25/2021 RE: Kelley Phillips August 25, 2021 Page 15 spine due to metallic susceptibility artifact from anterior cervical fusion hardware. The visualized portions of the upper cervical and upper thoracic cord are within normal limits. On August 30, 2017, a CT scan of the cervical spine was performed at Palm Bay Hospital. The impression revealed status post anterior cervical discectomy and fusion spanning C4 through C7 as described above without evidence of hardware loosening or failure. The canal and neuroforamina appear patent. Limited evaluation of the thecal sac contents shows no gross abnormalities. On September 16, 2017, x-rays of the thoracic and lumbar spines were performed at Palm Bay Hospital. The impression stated degenerative and postsurgical changes, no acute fracture. These studies were compared to x-rays dated March 28, 2014, and a CT scan dated July 3, 2016. On September 26, 2017, an MRI of the thoracic spine was performed at Weiss & Newberry Medical Associates. The impression stated normal MRI scan of the thoracic spine. On September 26, 2017, an MRI of the cervical spine was performed at Weiss & Newberry Medical Associates. The impression stated normal MRI scan of the cervical spine except for postop changes starting at C4 and going caudally with artifact at C6-C7. On September 27, 2017, an MRI of the brain was performed at Weiss & Newberry Medical Associates. This study was compared to previous images performed on February 26, 2014. The impression revealed mildly abnormal MRI of the brain with and without paramagnetic contrast agent with periventricular changes maximum at the anterior horns bilaterally and two additional small white matter lesions on FLAIR which are nonspecific in etiology. On October 9, 2017, an MRI of the lumbar spine