Preview
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
April 9, 2021
Ms. Yekaterina Kovtunova
Lewis, Brisbois, Bisgaard & Smith, LLP
77 Water Street, Suite 2100
New York, NY 10005
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
Dear Ms. Kovtunova:
I had the opportunity to examine Ms. Almendaraz at my office at 955 Fifth Avenue,
New York City, New York, 10075, at approximately 9:00 AM on March 3, 2021. Ms.
Almendaraz’s New York State driver’s license was used for identification. Ms.
Alexandria Guttierez was present throughout to interpret to and from Spanish. She
was otherwise unaccompanied. A female medical assistant was present for the
examination. Covid 19 precautions were taken.
The history as obtained from Ms. Almendaraz is that she is a 49-year-old, right-
hand-dominant woman involved in a motor vehicle accident on 9/25/2018. She
claims that she was the restrained driver of a vehicle that was stopped and then
struck in the rear of her vehicle by a truck that was backing up. She claims it was a
very strong hit. She claims she did not strike her head. She claims she was
unconscious for approximately 2 minutes. From the scene she went home. She
claims three days later she sought medical attention. She claims she had neck
pain, back pain and right arm pain immediately following the incident. She reports
she had pain in the posterior neck traveling down her back. She reports she was
treated with physical therapy, acupuncture, chiropractics and then underwent laser
surgery. Prior to her surgery she describes her neck pain was a 10 on a scale of 0
to 10. The neck pain is now a 6 to 7 on a scale of 0 to 10. She reports she is
receiving injections once a month. She denies radiation of the pain into the upper
extremities. She claims she has numbness of the entirety of her right upper
extremity. She claims she never has a pain free day. She claims the pain is
present 24/7. She reports she is under the care of Dr. Shahid.
1
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
She claims her back pain began immediately following the alleged injury. She
describes the pain was in the middle of her back and her lower back. Her lower
back pain was treated with surgery in November of 2020. She describes the
surgery helped a lot, and now she has minimal lower back pain. Prior to the surgery
the pain was in the lower back. Currently, she has complaints of pain in the mid
portion of the upper back at approximately the level of her bra strap. At times, that
pain radiates to the entire back. It ranges from a 7 to a 10 on a scale of 0 to 10 and
is particularly bad at night. She claims she is receiving injections for that pain. She
has no lower extremity pain. She denies numbness, tingling or weakness of her
legs.
She denies problems with her spine prior to this event. She denies prior injuries. At
the time of the accident, she describes she was employed in a restaurant working;
cooking, making salads, and pastries. She was working 40 hours a week. At some
point in 2019, she claims she had to drop down to 20 hours a week. She is
currently working 20 hours a week performing the same activities. She describes
her pains are aggravated when she has to lift heavy objects. She reports she feels
better for approximately 2 weeks following her injections. She did not specify the
type of injection. She claims she can sit comfortably for 20 to 30 minutes and is
unable to stand in one place comfortably. She denies restrictions in terms of
walking. She denies bladder or bowel dysfunction. She denies surgery other than
the procedure on her neck and the procedure on her lower back. She denies other
medical problems. Current medications are Tylenol as needed. She reports she is
taking medications for her pain but does not know the names of them. She denies
alcohol and tobacco use. Her son drove her to the examination today. She reports
she is able to perform her activities of daily living but claims she has difficulty
brushing her hair. She is able to drive.
Ms. Almendaraz was instructed before the examination and during the examination
to report any pain and to avoid performing any maneuvers that she felt could
worsen her symptoms or condition. She indicated that she understood this.
Opportunities for breaks during the examination were offered. The examination was
completed without complaints or signs of injury.
2
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
On examination she is a pleasant, cooperative woman in no apparent distress. She
independently changed into a gown for the examination. She gets up and down
from the exam table independently and moves about the room without difficulty.
She is able to go from a sitting to a lying and back to a sitting position without
apparent difficulty. Ms. Gutierrez and a medical assistant were present for the
examination . She is 5’4” tall and weighs 165 pounds. She has a normal gait. She
is able to demonstrate toe walk, heel walk and perform tandem gait. On active
range of motion testing of the lumbar spine she demonstrates 90 degrees of
flexion, 20 degrees of extension, 20 degrees of right and left bending and 45
degrees of right and left lateral rotation. On active range of motion testing of the
cervical spine she demonstrates 45 degrees of flexion, 50 degrees of extension, 40
degrees of right and left lateral bending, and 80 degrees of right and left lateral
rotation. A goniometer is used to assist in measurement. Measurements are
rounded to the nearest five degrees.
Normal range of motion lumbar spine:
Flexion 60 degrees
Extension 25 degrees
Lateral right bending 25 degrees
Lateral left bending 25 degrees
Rotation to the right 30 degrees
Rotation to the left 30 degrees
Normal range of motion of the cervical spine:
Flexion 50 degrees
Extension 60 degrees
Lateral bending to the right 45 degrees
Lateral bending to the left 45 degrees
Lateral rotation to the right 80 degrees
Lateral rotation to the left 80 degrees
Motor examination of the upper and lower extremities is 5/5 throughout. Each
muscle group is individually tested and found to be satisfactory. There is no
evidence of clonus, Hoffmann’s, Babinski’s or Spurling signs. Deep tendon reflexes
were 2 plus in the upper extremities and 2 plus in the lower extremities,
symmetrically bilaterally. Sensation to light touch was equal and intact throughout.
3
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
Range of motion of the hips was not painful. FABER’s test was negative bilaterally.
Straight leg raising is negative bilaterally in both the seated and supine positions.
There was no atrophy noted. There was no deformity of the spine noted. Leg
lengths were equal. There were no incisions noted in the neck. A scar of
approximately 5 mm was noted in the lateral paraspinal muscles on the left side of
the lower back. There was no paraspinal muscle spasm or tenderness noted.
I reviewed the following medical records and documents:
1. Plaintiff’s bill of particulars.
2. Plaintiff’s supplemental bill of particulars; 3/24/2020.
3. Plaintiff’s second supplemental bill of particulars; 11/20/2020.
4. Police accident report; 9/25/2018.
5. Medical records, Sky Radiology.
6. Medical records, Nasar Shahid, M.D.
7. Operative report; 7/22/2019.
8. Operative report; 10/10/2020,
9. Medical records, Long Island Physical Medicine and Rehabilitation.
10. Medical records, Englewood Orthopedic Group.
11. Police accident report; 6/28/2018 (prior MVA).
12. Medical records, Diagnostic Imaging of Rockville Centre.
13. Transcript of examination before trial of Ms. Almendaraz; 8/25/2020.
14. Deposition exhibits including photographs of vehicle.
15. Transcript of examination before trial testimony of Richard Cucci;
10/28/2020.
16. Biomechanics report of Dr. Calum G. A. McRae, PhD, Senior Biomechanist,
ARCCA; 2/25/2021.
17. Independent examination, Dr. Scarpinato; 1/28/2021
I reviewed the following reports and/or imaging studies:
1. MRI of the lumbar spine; Diagnostic Imaging of Rockville Centre. Study
1/12/2019, Report 1/13/2019.
2. MRI of the cervical spine, Sky Radiology: Study 11/9/18, Report 11/15/18.
3. X-rays of the cervical spine performed on 4/24/2019
4. Thoracic spine visualized on a chest x-ray performed 4/24/2019
4
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
I reviewed the police accident report of a motor vehicle accident on 6/28/2018,
(approximately 4 weeks prior to this alleged injury). The vehicle Ms. Almendaraz
was driving collided with another vehicle on a Southern State Parkway entrance
ramp.
I reviewed the police accident report dated 9/25/2018. The accident description
was while backing trailer southbound on Henry Street had collision with rear portion
of vehicle 2 (Ms. Almendaraz’s vehicle).
A photograph of a vehicle with License Plate DYP6243 shows the posterior trunk is
damaged.
Evaluation at the Nassau Health Wellness, PC on 10/2/2018 indicates diminished
range of motion of the cervical spine with tenderness and pain in the posterior neck.
Muscle spasm was noted in the paracervical, paraspinal and trapezius muscles.
She was noted to have full range of motion of the lumbar spine. Neurologic
evaluation was unremarkable. Examination was performed by Joseph Lewis, M.D.
The examination is most consistent with a cervical sprain/strain.
I reviewed the report of an MRI of the cervical spine performed at Sky Radiology.
The study was performed 11/9/2018. The report is dated 11/15/2018. The report
indicates C5-C6 and C6-C7 broad-based posterior central subligamentous
herniations with regional nerve root impingement, concomitant posterior disc bulge
between C3 and C7 encroaching upon the regional nerve roots. I reviewed the MRI
images of the cervical spine performed at Sky Radiology on 11/9/2018. A minimal
central disc herniation is noted at C6-C7. It is not causing spinal cord or nerve root
compression. There is no objective indication the pathology noted is causally
related to the alleged motor vehicle accident. The pathology is minimal. There is
no objective indication the pathology noted is the source of Ms. Almendaraz’s
complaints. The pathology does not warrant surgical intervention. Her subjective
complaints are out of proportion to the objective findings on the MRI study.
Medical records from Dr. Shahid indicate an initial visit on 12/3/2018. A 47-year-old
right-hand-dominant Leticia Almendaraz presents for initial consultation for neck
and low back due to injuries sustained in motor vehicle accident on 9/25/2018. The
5
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
6/28/18 prior car accident is not mentioned. During the accident, she did not lose
consciousness. (This is contrary to the information provided to me.) Due to sharp
pain radiating down the neck she went to see her PCP where she was evaluated
and referred here. She was complaining of neck and lower back pain, both of which
were 8 on a scale of 0 to 10. She was noted to have restricted range of motion of
the lumbar spine. Spasm and tenderness were noted in the paraspinal muscles of
the neck and lower back with positive Spurling’s sign and positive straight leg
raising on the right. Motor examination was normal. Sensation was noted to be
decreased in the right C5-C6 dermatomal distribution. She was referred for
physical therapy. Dr. Shahid performed both cervical and lumbar injections.
I reviewed the report of an EMG/NCV study performed 12/3/2018 and interpreted by
Dr. Shahid as showing evidence of a right C5-C6 cervical radiculopathy.
I reviewed the report of an MRI of the lumbar spine performed at Diagnostic
Imaging of Rockville Centre. The study was performed 1/12/2019 (report dated
1/13/2019). The report indicates L4-L5 and L5-S1 interspace narrowing and
dehydration, L3-L4 bilateral facet arthropathy, L4-L5 broad-based disc bulge with
bilateral neural foraminal lateral recess stenosis and facet arthropathy, L5-S1
central disc bulge with relative left-side neural foraminal narrowing and lateral
recess stenosis. I reviewed the MRI images of the lumbar spine performed 1/12/19
at Diagnostic Imaging of Rockville Centre. Mild degenerative changes are noted at
L4-L5 and L5-S1 levels. I do not appreciate the disc herniation or nerve root
compression reported. The pathology is minimal. There is no objective indication
the pathology noted is the source of Ms. Almendaraz’s complaints. There is no
evidence of acute injury or nerve root compression noted. There is no surgical
pathology noted on the study. The pathology noted does not warrant surgery. Her
subjective complaints are out of proportion to the objective findings on the MRI
study.
A treatment note from Englewood Orthopedic Group, Dr. Jamie Gutierrez, dated
4/23/2019 indicates Ms. Almendaraz is a 47-year-old right-hand-dominant female
involved in motor vehicle accident on 9/25/2018. She denied any loss of
consciousness. Ambulance arrived at the scene, but patient did not go to the
hospital at the same time. She was seen by a primary care physician who referred
her to physical therapy program. There is no mention of spine-related problems.
6
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
I reviewed the X-rays of the cervical spine performed on 4/24/2019 ordered by Dr.
Gutierrez. They are unremarkable. I reviewed the chest x-ray. The thoracic spine
visualized on the chest x-ray performed 4/24/2019 demonstrates a minimal pre-
existing scoliosis without evidence of acute injury.
I reviewed the report of an EMG/NCV study performed 1/21/2019 and interpreted by
Dr. Shahid as showing evidence of a left L5-S1 lumbosacral radiculopathy.
I reviewed an operative report dated 10/20/2020 from the Clinton Medical Office.
The procedure was performed under local anesthesia with sedation of the ASC of
Rockaway Surgical Center. The operative procedure reported is discectomy,
nucleus pulposus ablation, annuloplasty, contrast injection and evaluation of
nucleogram, transforaminal epidural steroid injection. This was performed at the
L4-L5 level. There was no objective causally related indication for the procedure.
The procedure is one of dubious value not generally performed by spine surgeons.
In summary, Ms. Almendaraz was allegedly involved in a motor vehicle accident on
9/25/2018. By description it was a low energy injury collision. Review of the report
from ARCCA performed by Dr. Calum G. A. McRae, PhD, Senior Biomechanist,
concludes similarly. His analysis is accelerations experienced were within the limits
of human tolerance. There was no injury mechanism present in the subject incident
to account for Ms. Almendaraz’s claimed cervical spine or lumbar spine injuries.
There was no objective causally related evidence the minimal abnormalities noted
on the claimant’s cervical and lumbar spine MRI’s were causally-related to the
alleged injury. There was no objective causally related indication for the lumbar
spine procedure performed. I do not see a report of cervical spine surgery as
claimed by Ms. Almendaraz during our meeting. There is no claim of cervical spine
surgery. Cervical injections do not constitute surgery.
Dr. Scarpinato concluded there was no objective evidence of an injury to the spine
beyond a cervical and thoracolumbar sprain, since resolved. There is no residual
deficit vis a vis the spine.
7
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
Currently, Ms. Almendaraz has subjective complaints with regard to her spine. She
has an unremarkable examination of the thoracic and lumbar spine with full range of
motion and normal neurologic examination relative to the lumbar spine. There is no
objective evidence of a causally related injury to the thoracic and/or lumbar spine.
There is no objective causally related indication for further testing or treatment of
the thoracic or lumbar spine. There is no objective causally-related contraindication
to Ms. Almendaraz participating in unrestricted activities of work and daily living with
regard to the thoracic and lumbar spine.
With regard to the cervical spine, there is no objective evidence of a causally related
injury to the cervical spine. Ms. Almendaraz has subjective complaints of functional
disability. Those subjective complaints are not supported by the objective evidence
available. She has an unremarkable examination of the cervical spine. She is
neurologically intact. Imaging studies showed no objective evidence of an injury to
the cervical spine. Ms. Almendaraz’s subjective complaints are not supported by
the objective information available. Ms. Almendaraz claims to have undergone
cervical spine surgery. I do not appreciate an operative report of cervical spine
surgery. She underwent injections in the cervical spine. There is no objective
indication those injections were objectively causally related to the alleged injury.
I, Paul Kuflik MD., being a Diplomate of the American Board of Orthopedic
Surgeons, am duly licensed to practice medicine in the State of New York pursuant
to CPLR, section 210.6 and hereby affirm under the penalties of perjury the
foregoing is true to the best of my knowledge except as to those matters stated on
information and belief, and as to those matters I believe to be true.
The above claimant was examined according to the restrictive rules concerning an
independent medical examination. It is therefore understood no doctor patient
relationship exists or is implied by this examination.
The claimant is examined in reference to that specific complaint emanating from the
original injury. Any other medical conditions, which were either unreported or felt to
be unrelated to the original injury, are considered to be beyond the purview of this
examination.
Sincerely yours,
8
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019
NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021
Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075
Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530
Mt. Sinai School of Medicine
Spine Surgery
www.Drpaulkuflik.com Mailing Address: Please send all correspondence to:
516 739 9270 912 Harvard Ct. Woodmere, NY 11598
Paul Kuflik MD
Associate Professor of Orthopedic Surgery
Mount Sinai School of Medicine
PK/lm
9
Re: Leticia Almendaraz
File #42714.38
Date of Injury: 9/25/2018
Preview
FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 April 9, 2021 Ms. Yekaterina Kovtunova Lewis, Brisbois, Bisgaard & Smith, LLP 77 Water Street, Suite 2100 New York, NY 10005 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 Dear Ms. Kovtunova: I had the opportunity to examine Ms. Almendaraz at my office at 955 Fifth Avenue, New York City, New York, 10075, at approximately 9:00 AM on March 3, 2021. Ms. Almendaraz’s New York State driver’s license was used for identification. Ms. Alexandria Guttierez was present throughout to interpret to and from Spanish. She was otherwise unaccompanied. A female medical assistant was present for the examination. Covid 19 precautions were taken. The history as obtained from Ms. Almendaraz is that she is a 49-year-old, right- hand-dominant woman involved in a motor vehicle accident on 9/25/2018. She claims that she was the restrained driver of a vehicle that was stopped and then struck in the rear of her vehicle by a truck that was backing up. She claims it was a very strong hit. She claims she did not strike her head. She claims she was unconscious for approximately 2 minutes. From the scene she went home. She claims three days later she sought medical attention. She claims she had neck pain, back pain and right arm pain immediately following the incident. She reports she had pain in the posterior neck traveling down her back. She reports she was treated with physical therapy, acupuncture, chiropractics and then underwent laser surgery. Prior to her surgery she describes her neck pain was a 10 on a scale of 0 to 10. The neck pain is now a 6 to 7 on a scale of 0 to 10. She reports she is receiving injections once a month. She denies radiation of the pain into the upper extremities. She claims she has numbness of the entirety of her right upper extremity. She claims she never has a pain free day. She claims the pain is present 24/7. She reports she is under the care of Dr. Shahid. 1 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 She claims her back pain began immediately following the alleged injury. She describes the pain was in the middle of her back and her lower back. Her lower back pain was treated with surgery in November of 2020. She describes the surgery helped a lot, and now she has minimal lower back pain. Prior to the surgery the pain was in the lower back. Currently, she has complaints of pain in the mid portion of the upper back at approximately the level of her bra strap. At times, that pain radiates to the entire back. It ranges from a 7 to a 10 on a scale of 0 to 10 and is particularly bad at night. She claims she is receiving injections for that pain. She has no lower extremity pain. She denies numbness, tingling or weakness of her legs. She denies problems with her spine prior to this event. She denies prior injuries. At the time of the accident, she describes she was employed in a restaurant working; cooking, making salads, and pastries. She was working 40 hours a week. At some point in 2019, she claims she had to drop down to 20 hours a week. She is currently working 20 hours a week performing the same activities. She describes her pains are aggravated when she has to lift heavy objects. She reports she feels better for approximately 2 weeks following her injections. She did not specify the type of injection. She claims she can sit comfortably for 20 to 30 minutes and is unable to stand in one place comfortably. She denies restrictions in terms of walking. She denies bladder or bowel dysfunction. She denies surgery other than the procedure on her neck and the procedure on her lower back. She denies other medical problems. Current medications are Tylenol as needed. She reports she is taking medications for her pain but does not know the names of them. She denies alcohol and tobacco use. Her son drove her to the examination today. She reports she is able to perform her activities of daily living but claims she has difficulty brushing her hair. She is able to drive. Ms. Almendaraz was instructed before the examination and during the examination to report any pain and to avoid performing any maneuvers that she felt could worsen her symptoms or condition. She indicated that she understood this. Opportunities for breaks during the examination were offered. The examination was completed without complaints or signs of injury. 2 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 On examination she is a pleasant, cooperative woman in no apparent distress. She independently changed into a gown for the examination. She gets up and down from the exam table independently and moves about the room without difficulty. She is able to go from a sitting to a lying and back to a sitting position without apparent difficulty. Ms. Gutierrez and a medical assistant were present for the examination . She is 5’4” tall and weighs 165 pounds. She has a normal gait. She is able to demonstrate toe walk, heel walk and perform tandem gait. On active range of motion testing of the lumbar spine she demonstrates 90 degrees of flexion, 20 degrees of extension, 20 degrees of right and left bending and 45 degrees of right and left lateral rotation. On active range of motion testing of the cervical spine she demonstrates 45 degrees of flexion, 50 degrees of extension, 40 degrees of right and left lateral bending, and 80 degrees of right and left lateral rotation. A goniometer is used to assist in measurement. Measurements are rounded to the nearest five degrees. Normal range of motion lumbar spine: Flexion 60 degrees Extension 25 degrees Lateral right bending 25 degrees Lateral left bending 25 degrees Rotation to the right 30 degrees Rotation to the left 30 degrees Normal range of motion of the cervical spine: Flexion 50 degrees Extension 60 degrees Lateral bending to the right 45 degrees Lateral bending to the left 45 degrees Lateral rotation to the right 80 degrees Lateral rotation to the left 80 degrees Motor examination of the upper and lower extremities is 5/5 throughout. Each muscle group is individually tested and found to be satisfactory. There is no evidence of clonus, Hoffmann’s, Babinski’s or Spurling signs. Deep tendon reflexes were 2 plus in the upper extremities and 2 plus in the lower extremities, symmetrically bilaterally. Sensation to light touch was equal and intact throughout. 3 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 Range of motion of the hips was not painful. FABER’s test was negative bilaterally. Straight leg raising is negative bilaterally in both the seated and supine positions. There was no atrophy noted. There was no deformity of the spine noted. Leg lengths were equal. There were no incisions noted in the neck. A scar of approximately 5 mm was noted in the lateral paraspinal muscles on the left side of the lower back. There was no paraspinal muscle spasm or tenderness noted. I reviewed the following medical records and documents: 1. Plaintiff’s bill of particulars. 2. Plaintiff’s supplemental bill of particulars; 3/24/2020. 3. Plaintiff’s second supplemental bill of particulars; 11/20/2020. 4. Police accident report; 9/25/2018. 5. Medical records, Sky Radiology. 6. Medical records, Nasar Shahid, M.D. 7. Operative report; 7/22/2019. 8. Operative report; 10/10/2020, 9. Medical records, Long Island Physical Medicine and Rehabilitation. 10. Medical records, Englewood Orthopedic Group. 11. Police accident report; 6/28/2018 (prior MVA). 12. Medical records, Diagnostic Imaging of Rockville Centre. 13. Transcript of examination before trial of Ms. Almendaraz; 8/25/2020. 14. Deposition exhibits including photographs of vehicle. 15. Transcript of examination before trial testimony of Richard Cucci; 10/28/2020. 16. Biomechanics report of Dr. Calum G. A. McRae, PhD, Senior Biomechanist, ARCCA; 2/25/2021. 17. Independent examination, Dr. Scarpinato; 1/28/2021 I reviewed the following reports and/or imaging studies: 1. MRI of the lumbar spine; Diagnostic Imaging of Rockville Centre. Study 1/12/2019, Report 1/13/2019. 2. MRI of the cervical spine, Sky Radiology: Study 11/9/18, Report 11/15/18. 3. X-rays of the cervical spine performed on 4/24/2019 4. Thoracic spine visualized on a chest x-ray performed 4/24/2019 4 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 I reviewed the police accident report of a motor vehicle accident on 6/28/2018, (approximately 4 weeks prior to this alleged injury). The vehicle Ms. Almendaraz was driving collided with another vehicle on a Southern State Parkway entrance ramp. I reviewed the police accident report dated 9/25/2018. The accident description was while backing trailer southbound on Henry Street had collision with rear portion of vehicle 2 (Ms. Almendaraz’s vehicle). A photograph of a vehicle with License Plate DYP6243 shows the posterior trunk is damaged. Evaluation at the Nassau Health Wellness, PC on 10/2/2018 indicates diminished range of motion of the cervical spine with tenderness and pain in the posterior neck. Muscle spasm was noted in the paracervical, paraspinal and trapezius muscles. She was noted to have full range of motion of the lumbar spine. Neurologic evaluation was unremarkable. Examination was performed by Joseph Lewis, M.D. The examination is most consistent with a cervical sprain/strain. I reviewed the report of an MRI of the cervical spine performed at Sky Radiology. The study was performed 11/9/2018. The report is dated 11/15/2018. The report indicates C5-C6 and C6-C7 broad-based posterior central subligamentous herniations with regional nerve root impingement, concomitant posterior disc bulge between C3 and C7 encroaching upon the regional nerve roots. I reviewed the MRI images of the cervical spine performed at Sky Radiology on 11/9/2018. A minimal central disc herniation is noted at C6-C7. It is not causing spinal cord or nerve root compression. There is no objective indication the pathology noted is causally related to the alleged motor vehicle accident. The pathology is minimal. There is no objective indication the pathology noted is the source of Ms. Almendaraz’s complaints. The pathology does not warrant surgical intervention. Her subjective complaints are out of proportion to the objective findings on the MRI study. Medical records from Dr. Shahid indicate an initial visit on 12/3/2018. A 47-year-old right-hand-dominant Leticia Almendaraz presents for initial consultation for neck and low back due to injuries sustained in motor vehicle accident on 9/25/2018. The 5 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 6/28/18 prior car accident is not mentioned. During the accident, she did not lose consciousness. (This is contrary to the information provided to me.) Due to sharp pain radiating down the neck she went to see her PCP where she was evaluated and referred here. She was complaining of neck and lower back pain, both of which were 8 on a scale of 0 to 10. She was noted to have restricted range of motion of the lumbar spine. Spasm and tenderness were noted in the paraspinal muscles of the neck and lower back with positive Spurling’s sign and positive straight leg raising on the right. Motor examination was normal. Sensation was noted to be decreased in the right C5-C6 dermatomal distribution. She was referred for physical therapy. Dr. Shahid performed both cervical and lumbar injections. I reviewed the report of an EMG/NCV study performed 12/3/2018 and interpreted by Dr. Shahid as showing evidence of a right C5-C6 cervical radiculopathy. I reviewed the report of an MRI of the lumbar spine performed at Diagnostic Imaging of Rockville Centre. The study was performed 1/12/2019 (report dated 1/13/2019). The report indicates L4-L5 and L5-S1 interspace narrowing and dehydration, L3-L4 bilateral facet arthropathy, L4-L5 broad-based disc bulge with bilateral neural foraminal lateral recess stenosis and facet arthropathy, L5-S1 central disc bulge with relative left-side neural foraminal narrowing and lateral recess stenosis. I reviewed the MRI images of the lumbar spine performed 1/12/19 at Diagnostic Imaging of Rockville Centre. Mild degenerative changes are noted at L4-L5 and L5-S1 levels. I do not appreciate the disc herniation or nerve root compression reported. The pathology is minimal. There is no objective indication the pathology noted is the source of Ms. Almendaraz’s complaints. There is no evidence of acute injury or nerve root compression noted. There is no surgical pathology noted on the study. The pathology noted does not warrant surgery. Her subjective complaints are out of proportion to the objective findings on the MRI study. A treatment note from Englewood Orthopedic Group, Dr. Jamie Gutierrez, dated 4/23/2019 indicates Ms. Almendaraz is a 47-year-old right-hand-dominant female involved in motor vehicle accident on 9/25/2018. She denied any loss of consciousness. Ambulance arrived at the scene, but patient did not go to the hospital at the same time. She was seen by a primary care physician who referred her to physical therapy program. There is no mention of spine-related problems. 6 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 I reviewed the X-rays of the cervical spine performed on 4/24/2019 ordered by Dr. Gutierrez. They are unremarkable. I reviewed the chest x-ray. The thoracic spine visualized on the chest x-ray performed 4/24/2019 demonstrates a minimal pre- existing scoliosis without evidence of acute injury. I reviewed the report of an EMG/NCV study performed 1/21/2019 and interpreted by Dr. Shahid as showing evidence of a left L5-S1 lumbosacral radiculopathy. I reviewed an operative report dated 10/20/2020 from the Clinton Medical Office. The procedure was performed under local anesthesia with sedation of the ASC of Rockaway Surgical Center. The operative procedure reported is discectomy, nucleus pulposus ablation, annuloplasty, contrast injection and evaluation of nucleogram, transforaminal epidural steroid injection. This was performed at the L4-L5 level. There was no objective causally related indication for the procedure. The procedure is one of dubious value not generally performed by spine surgeons. In summary, Ms. Almendaraz was allegedly involved in a motor vehicle accident on 9/25/2018. By description it was a low energy injury collision. Review of the report from ARCCA performed by Dr. Calum G. A. McRae, PhD, Senior Biomechanist, concludes similarly. His analysis is accelerations experienced were within the limits of human tolerance. There was no injury mechanism present in the subject incident to account for Ms. Almendaraz’s claimed cervical spine or lumbar spine injuries. There was no objective causally related evidence the minimal abnormalities noted on the claimant’s cervical and lumbar spine MRI’s were causally-related to the alleged injury. There was no objective causally related indication for the lumbar spine procedure performed. I do not see a report of cervical spine surgery as claimed by Ms. Almendaraz during our meeting. There is no claim of cervical spine surgery. Cervical injections do not constitute surgery. Dr. Scarpinato concluded there was no objective evidence of an injury to the spine beyond a cervical and thoracolumbar sprain, since resolved. There is no residual deficit vis a vis the spine. 7 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 Currently, Ms. Almendaraz has subjective complaints with regard to her spine. She has an unremarkable examination of the thoracic and lumbar spine with full range of motion and normal neurologic examination relative to the lumbar spine. There is no objective evidence of a causally related injury to the thoracic and/or lumbar spine. There is no objective causally related indication for further testing or treatment of the thoracic or lumbar spine. There is no objective causally-related contraindication to Ms. Almendaraz participating in unrestricted activities of work and daily living with regard to the thoracic and lumbar spine. With regard to the cervical spine, there is no objective evidence of a causally related injury to the cervical spine. Ms. Almendaraz has subjective complaints of functional disability. Those subjective complaints are not supported by the objective evidence available. She has an unremarkable examination of the cervical spine. She is neurologically intact. Imaging studies showed no objective evidence of an injury to the cervical spine. Ms. Almendaraz’s subjective complaints are not supported by the objective information available. Ms. Almendaraz claims to have undergone cervical spine surgery. I do not appreciate an operative report of cervical spine surgery. She underwent injections in the cervical spine. There is no objective indication those injections were objectively causally related to the alleged injury. I, Paul Kuflik MD., being a Diplomate of the American Board of Orthopedic Surgeons, am duly licensed to practice medicine in the State of New York pursuant to CPLR, section 210.6 and hereby affirm under the penalties of perjury the foregoing is true to the best of my knowledge except as to those matters stated on information and belief, and as to those matters I believe to be true. The above claimant was examined according to the restrictive rules concerning an independent medical examination. It is therefore understood no doctor patient relationship exists or is implied by this examination. The claimant is examined in reference to that specific complaint emanating from the original injury. Any other medical conditions, which were either unreported or felt to be unrelated to the original injury, are considered to be beyond the purview of this examination. Sincerely yours, 8 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018 FILED: NASSAU COUNTY CLERK 08/17/2021 03:36 PM INDEX NO. 612349/2019 NYSCEF DOC. NO. 52 RECEIVED NYSCEF: 08/17/2021 Paul L. Kuflik, MD Office Address: 955 Fifth Ave, New York, NY 10075 Associate Professor 1122 Franklin Ave. Suite 106, Garden City, NY 11530 Mt. Sinai School of Medicine Spine Surgery www.Drpaulkuflik.com Mailing Address: Please send all correspondence to: 516 739 9270 912 Harvard Ct. Woodmere, NY 11598 Paul Kuflik MD Associate Professor of Orthopedic Surgery Mount Sinai School of Medicine PK/lm 9 Re: Leticia Almendaraz File #42714.38 Date of Injury: 9/25/2018