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Spine Work Injury and Sciatica in Your L&I Claim

After a back or spine work injury, sciatica is a diagnosis that can come up in your L&I claim. What is it? How does sciatica arise in workers’ compensation claims? For that, it helps to have a basic understanding of the anatomy of the spine. I’m certainly not a medical professional. But, over the course of my career, I had to perform research and listen to countless hours of medical testimony. From there, I developed a basic understanding of the anatomy of the human spine, common spinal conditions, and how sciatica can occur. This basic knowledge helps me understand what my clients are going through with sciatica.

Anatomy of the human spine

The human spine is our backbone. Technically, it is made up of 33 individual bones called vertebrae. These bones stack one on top of the other. In addition, the spine comprises of discs, nerves, and the spinal cord itself. This structure is often called the spinal column. It provides the main support for the upright human body. Moreover, it connects different parts of the musculoskeletal system. On top of being a support structure, the spine is also an important protective structure. The spinal column protects spinal nerves from injury.

What is the Vertebrae?

The average adult human spine is made up of 26 vertebrae. That’s because some of the vertebrae in the spine fuse as humans age. The vertebrae are small bones, which are stacked to form the spinal canal. The spinal canal is essentially a tunnel. The spinal cord and nerves run through the tunnel. Most of the vertebrae in the spine can move, which allows humans to sit, stand, walk, twist, and bend.

What are the Facet Joints?

Vertebrae bones have multiple segments. The segments towards the outer part of the spine are called lamina. Then, the inner segments abutting the spinal column are called the pedicles. For each vertebra, between the lamina and pedicle, there’s slippery cartilage called the facet joints. These cartilage joints allow the vertebrae to slide against each other. This movement allows for greater range of motion and spinal column stability.

The discs in our spine

The discs, also called intervertebral discs, are a type of cushion. Spinal discs have an outer ring. The ring is made up of fibrous cartilage that encases a jelly-like core called the nucleus pulposus. The nucleus pulposus is mainly composed of water, but it also contains collagen. In essence, the discs act as a shock absorber and cushion between each vertebra.

Spinal cord and nerves

The spinal cord is a group of important nerves. These nerves run through the spinal canal from the base of the skull to the low back. They connect the brain to the various muscle groups throughout the body. In short, the nerves conduct electric signals or messages between the brain and the rest of the body. In turn, these signals enable both sensation and movement. Smaller nerves branch out from the spinal column at various vertebral levels to carry brain signals throughout the body.

What are vertebral regions?

The spine is often categorized into different regions or levels. The area of the spine near the neck is called the cervical region. There are 7 cervical vertebrae. Medical professionals refer to them as C1-C7. The mid back area of the spine is called the thoracic region. There are 12 thoracic vertebrae, which we refer to as T1-T12. Finally, the low back is called the lumbar region. There are 5 lumbar vertebrae that we label as L1-L5.

Just below the lumbar vertebrae is the sacrum or sacral region. The sacrum comprises 5 fused vertebrae, which doctors call S1-S5. The sacral cord segments in this region of the spine are sometimes called the “Cauda Equina”. Just below the sacrum is the coccyx or tailbone. It consists of 4 fused vertebrae.

Spinal degeneration and L&I claim challenges

The spine supports the human body. It enables flexibility and movement in many directions. Furthermore, it protects the nerves of the spinal column. While the spine is impressive, it is not unfailing. The spine does have flaws. Notably, nearly every component of the spine is impacted by aging. Over time, the spine loses its normal structure and function. It becomes more susceptible to damage and injury.

Throughout my career, I’ve heard spinal degeneration called many different things. The terms doctors use include arthritis, degenerative disc disease, and degenerative spine disease. Sometimes, medical professionals call it degeneration, osteoarthritis, herniation and stenosis. Regardless of the specific diagnosis, spinal degeneration is incredibly common. In fact, I’ve heard medical doctors testify that degeneration in the spine can begin as early as the teenage years.

As the spine ages, common things that may occur include:

Loss of bone density resulting in more brittle and breakable bones
Formation of calcium deposits or bone spurs on the surfaces of the bones
Decrease in cartilage hydration, which increase the likelihood of fraying or tearing
Weakening of disc walls leading to compression, shape changes and leaking.

Spine work injury and general spinal injuries

In addition to weakening from natural aging, the human spine is also susceptible to injury. In turn, it can lead to sciatica diagnosis in your L&I claim. There are an infinite variety of ways the human spine can suffer an injury. For example, slip and fall, auto accident, bicycle and motorcycle accident, assault and gun violence, injuries that occur during childbirth, infectious diseases that attack the spine, sports injuries, and spine work injury. Depending on age, these spinal injuries can occur on top of natural degeneration. They can produce even greater symptoms. Common signs and symptoms of spinal cord injuries include numbness, paralysis, and swelling. Spinal work injuries can also cause difficulty breathing, loss of muscle control, weakness, loss of bowel and bladder function, and pain.

What is Sciatica?

The term sciatica generally refers to radiating pain down one or both legs. Usually, the cause is some sort of low back injury that impacts the “sciatic” nerves. The sciatic nerves branch out from the low back through the hips and buttocks. From there, they run down the legs. Generally, the sciatic nerves are the combination of spinal nerves originating at the L4-S3 level of the spine. With back work injury or spine workplace injury occurrences, workers usually report issues with the L3-S1 level of the spine.

Spine and low back work injury incidents are very common. They often occur as a result of:

BLT injuries: injuries that occur from the combination of bending, lifting and twisting;
Trips, slips and falls;
Heavy equipment accidents;
Automobile accidents;
Assaults; and
Occupational disease – repetitive use workplace injuries and degenerative conditions.

Sciatica diagnosis in an L&I claim

All these low back injuries can result in sciatica. Inflammation, disc herniation, injuries that cause narrowing of the spinal canal, formation of calcium deposits or spurs, damage to the foramen or other cartilage and ligaments, can put pressure on, impact and even damage the nerves on the low back.

Doctors may diagnose sciatica when the damage is within the L4-S3 and produces radiating pain or radiculopathy. Often, doctors diagnose sciatica based on certain clinical exam findings. However, many medical professionals prefer an MRI to confirm the diagnosis.

Treatment for sciatica in the L&I claim settings

Receiving a diagnosis of sciatica can be distressing for work injury claimants. The good news is that there are many effective treatment options. They don’t necessarily involve scary or invasive surgeries. In fact, L&I medical treatment guidelines require doctors to exhaust less invasive or conservative treatment options before considering extensive treatment. Therefore, the first common treatment for work injury claimants with sciatica is physical and massage therapy. It’s important to see if symptoms can resolve naturally. In fact, symptoms can improve by reducing inflammation, increasing mobility, and strengthening.

Sometimes, physical therapy is not successful. In such cases, doctors may request an MRI. Other times, the medical provider may recommend injections. Some injections can serve two purposes. They can help alleviate symptoms and help pinpoint the specific levels of the spine that are injured. For example, say you receive a pain reliever injection to the L4 disc. Moreover, assume it results in measurable pain relief. Therefore, it can help medical providers identify that symptoms originate from that level of the spine.

More invasive L&I claim treatment for sciatica after a work injury

In some cases, conservative treatment measures are unsuccessful. At that point, medical professionals can consider more invasive treatment such as surgery. To proceed, they will need an MRI and possibly an EMG. Even if they recommend surgery, under the L&I medical treatment guidelines, medical providers will likely start with less invasive surgery. For instance, a laminectomy or discectomy. These procedures clean up around the damaged area of the spine. In turn, it allows more mobility and for the nerves to be free.

Under the L&I medical treatment guidelines, only if conservative treatment fails, then medical providers can consider a major surgery like spinal fusion. That’s not always a good thing. Why? Because treatment will take a long time for less responsive and severe sciatica. This also means the L&I claim is likely to be longer and more complex.

Summary

In conclusion, sciatica refers to radiating pain in the low back. If you receive a sciatica diagnosis under your workers’ compensation claim, it is a good idea to have a basic understanding of the anatomy of the spine. That way, you can better understand your medical condition and the treatment recommendations. A diagnosis of sciatica does not necessarily mean you will need surgery. Also, it doesn’t mean long and painful recovery. Fortunately, many people recover successfully without surgery.

With sciatica, if your condition is more severe, you will need to be patient. Your treatment providers have to work through the various options, starting with more conservative ones. As you navigate your treatment, it is important to ask questions. Make sure you understand your diagnoses and treatment options. After that, make informed decisions. Finally, and throughout the process, track your body’s response to different treatments.

Important Dates You Must Remember in Your L&I Claim

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Calendar dates can be very important in an L&I claim. In fact, certain dates associated with specific events can impact your L&I claim benefits. In some cases, incorrect dates can even have long lasting negative implications in claims. The purpose of this article is to discuss some of the most important claim dates that work injury claimants must track and remember.

Date of injury in a workers’ compensation claim

The date of injury (DOI) is the date an Industrial Injury occurred. If you were injured at work on a specific day, that is your date of injury. It’s very important that you use the correct date of injury when filling the accident report. This date will also appear in other early claim documents. Personally, I’ve seen circumstances where L&I doubted the validity of the claim because the date of the work injury was wrong. For example, take a workplace injury that occurred on a Friday. Yet, the date of injury in the report form is listed as Saturday. This real-life error caused the employer to question the claim because the worker wasn’t at work on Saturday. One tiny mistake and the injured worker had to spend months convincing the employer and L&I that the injury actually happened on Friday while at work. Not at home over the weekend.

The date of injury is also very important because L&I uses it to calculate wages. Work injury claimants may be eligible to wage replacement benefits like time-loss compensation or loss of earning power. L&I pays these benefits when workers cannot work after their work injury. Or, when workers can only work in limited capacity. To determine compensation, L&I looks at the wages on the date of injury. Therefore, an accurate date of injury is important. It’s imperative that L&I calculates wages correctly and accurately.

Date of manifestation

The date of manifestation (DOM) is the date associated with the onset of an occupational disease claim. Under the law, the date of manifestation is “the date the disease required medical treatment or became totally or partially disabling, whichever occurred first”. The date of manifestation is set exactly according to this definition. It doesn’t matter when you actually filed your L& claim.

As with industrial injury, establishing a correct date of manifestation is very important. I’ve seen instances where L&I questioned a claim because the date of manifestation on the form was long after the first treatment date. This caused L&I to suspect that the work injury claimant wasn’t honest. It also opened the door for questions about whether the condition was actually an occupational disease. Or, for example, something that occurred naturally regardless of work activity.

If L& rejects a claim on this basis, it puts work injury claimants in a bad position. They end up having to fight an uphill battle to get the claim allowed. Using the correct date of manifestation from the beginning can eliminate this risk.

Incorrect dates can impact your claim benefits

The date of manifestation can also impact monetary benefits. Here are a few examples. Nearly every year, L&I sets a “compensation schedule”. For instance, say that the date of manifestation is in 2010. In addition, say that the work injury claimant is ultimately eligible for a permanent partial disability award. Eventually, L&I will pay the worker according to the PPD rates for 2010.

Another example is wage replacement benefits. Let’s assume that the work injury claimant is working when the industrial disease requires treatment. Then, L&I will base the wage replacement compensation on the monthly wage paid on that date. However, if the work injury claimant wasn’t employed at the date of manifestation, then L&I calculates the compensation using the last monthly wage of earnings. That is, so long as the worker didn’t retire voluntarily. In fact, voluntary retirement disqualifies work injury claimants from receiving wage replacement benefits.

L&I claim dates associated with letters and communications

Many L&I claim deadlines are a function of the date in which L&I sends out a document or notification. For example, if L&I sends an order, you have 60 days from the date you receive the order to file a protest or appeal. If you don’t file a protest within 60 days, then the order becomes final and binding. After that, you can no longer challenge the decision.

By law, L&I must send orders to work injury claimants at their last known address “as shown by the records of the department”. Hence, L&I considers the order delivery as “complete” when the mail arrives at the work injury claimant’s last known address. It’s important to note that workers can rebut this presumption. To do so, you must present evidence and show you didn’t receive the order. However, no one ever wants to be in this position. In my opinion, the best way to ensure you’re calculating deadlines properly is to simply write the date of receipt on every document. That’s how law firms do it. Every time a piece of mail comes in the door – we date-stamp it. Having a similar standard practice can help throughout your workman’s comp claim.

Terminal dates and claim reopening

Terminal dates are important when trying to reopen a claim. There are two important terminal dates. Both play a role during the claim reopening application. The first terminal date (called T1) is the latter of: (1) The date L&I closed the claim; or (2) The most recent date L&I denied a reopening application. The second terminal date is called T2. It is the most recent date when you filed an application to reopen the claim. Both T1 and T2 dates can change over time.

Let’s go over an example. A work injury claimant suffered an injury on the job on 1/1/2010. L&I allowed their claim on 1/5/2010. Later, L&I closed the claim on 12/31/2015. The worker applied to reopen the claim on 1/1/2016. In turn, L&I denied the reopening application on 2/1/2016. Here, the first terminate date is 12/31/2015. The second terminate date is 2/1/2016. Further, assume that the worker does not protest or appeal the denial. Instead, say the worker files a new application to reopen on 1/1/2017. Additionally, say that L&I denies the new reopening application on 2/1/2017. After that, the new T1 will be 2/1/2016 and T2 will be 2/1/2017.

Terminal dates are important in reopening applications. For L&I approval, you must show that claim-related conditions got worse between the terminal dates. Furthermore, you must show the need for further treatment or an increase in disability. So, it’s extremely important for both work injury claimants and their medical providers to understand the terminal dates.

L&I claim closing date

When L&I closes a claim, they send you a “Notice of Decision”. Sometimes, L&I sends a final “Payment Order” instead. Either way, the L&I claim closing date refers to the date that appears on that letter. This is one reason it’s very important to always read L&I orders completely and carefully.

When L&I decides it’s time to close your claim, they must issue their decision in writing. In it, L&I must clearly state that the claim is closed. Like any decision, to protest or appeal it, you must submit a written notice within 60 days. If L&I receives the protest in time, then L&I has to issue a new order. If L&I affirms its decision to close the claim, then the date on the new order becomes the claim closing date. Technically, a claim isn’t closed until 60 days after the written notice of closing arrives to the worker.

Sometimes, people don’t understand that L&I must communicate claim closure in writing. They mistakenly think that if a doctor tells them that treatment concludes, then the claim is closing. Other times, workers think that if a claim manager tells them the claim is closing, then it’s closed. In fact, I’ve talked to work injury claimants who believed their claims closed for years. Only to find out that their claims are still open. During this entire time, workers skipped medical treatment and benefits.

Appointment dates – Don’t forget your L&I appointment!

By far, the most important date(s) to remember in your L&I claim is your appointment date. Work injury claimants miss appointments way too frequently. Sure, unexpected issues and emergencies arise from time to time. However, it’s unacceptable to forget and ignore appointments repeatedly.

Whether it’s an appointment with your attending provider or IME appointments. Whether we’re talking about physical therapy, consultation appointments, or vocational meetings. It doesn’t matter. There is no justification to miss appointments. As such, it’s critical to know the date and attend your appointment on time. If you repeatedly miss appointments, it’s one surefire way to interrupt your L&I claim progress. Often, it will result in suspension of benefits. There is nothing more frustrating than finding out a work injury claim has gone down the toilet simply because the claimant failed to attend appointments.

I know a claim can be difficult. I’m well-aware it can be scary to manage all the appointments and administrative responsibilities. However, if your claim is important to you, know your appointment date and show up. Unless you have a very good reason for missing it.

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L&I Delivers Bad News to Injured Workers and Some of the Best Medical Advocates in Workers’ Compensation

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I recently posted an article about L&I’s Medical Aid Rules and Fee Schedules, which were recently published for 2023. In particular, the L&I Medical Aid Rules can be a great resource for helping work injury claimants understand treatment options. Furthermore, the L&I Fee Schedules can also have a significant impact on work injury claimants and stakeholders.

L&I cuts funding for Nurse Case Managers

As a workers’ compensation attorney who regularly publishes on issues relating to workers’ compensation issues in Washington State, I feel I would be remiss if I did not publicly address and unambiguously condemn L&I’s new fee structure for Nurse Case Managers. I am well aware that L&I has a duty to responsibly manage the Accident Fund. However, cutting fees for Nurse Case Managers is not the way to do it.

Last year, Nurse Case Managers were entitled to bill $116.60/hour for their work in L&I claims. This is a very reasonable rate given their level of education and experience requirements. This year, the 2023 L&I Fee Scheduled caps their fees at a flat rate of $200 per month. While I don’t personally have statistics on this, I strongly suspect the $200 flat fee comes nowhere close to adequately compensating Nurse Case Managers for the work they do. I anticipate that these funding cuts will result in experienced Nurse Case Managers declining to provide services in L&I claims. In fact, I’m already starting to see it happen.

What are Nurse Case Managers?

Nurse Case Managers (NCMs) are registered nurses with one of the following case management certifications: Certification of Disability Management Specialists (CDMS), Commission for Case Manager Certification (CCMC or CMC), Certified Rehabilitation Registered Nurse (CRRN), Certified Occupational Health Nurse (COHN), and/or Certified Occupational Health Nurse-Specialist (COHN-S). In other words, NCMs are highly educated and skilled healthcare professionals. An NCM can be assigned to assist in an L&I claim in many situations. For example, when there has been a catastrophic work-related injury not otherwise being managed under the “Catastrophic Project”. Another example is an L&I claim where the work injury claimant lives or has moved out of Washington State and needs assistance locating a provider. Other examples include an L&I claim involving medically complex conditions, or when there are other barriers impacting successful claim resolution.

As an L&I attorney representing work injury claimants, I have partnered effectively with NCMs on countless occasions to achieve results that benefit not only work injury claimants, but also L&I and other stakeholders. This is particularly true in Out-of-State cases, complex or catastrophic medical cases, and cases with other issues creating a barrier to appropriate claim progress.

How are Nurse Claim Managers useful in Out-of-State claims?

NCMs are instrumental in assisting us to obtain Out-of-State treatment providers. Usually, before we request assistance from a NCM, my staff undertakes to assist our clients with this process. However, due to the meager L&I fees for service providers, we are finding it more and more challenging to find willing Out-of-State treatment providers. Furthermore, we often find that despite our best efforts, treatment providers are turned off when a law office contacts them to inquire about providing L&I treatment to a work injury claimant. They usually assume our involvement means the claim is messy or legally contentious. This is often not the case.

Once my office has exhausted our resources trying to get an Out-of-State provider, we ask for an NCM to be assigned. In approximately 4 out of 5 cases, having a NCM assigned results in our ability to track down a willing Out-of-State provider despite our prior failed efforts. When a willing Out-of-State provider cannot be found, we are left with only one option: L&I must bear the expense of having the injured worker regularly travel to Washington State for treatment. Yes, this means L&I is paying for flights or other transportation, hotels, and meals, on regular intervals for work injury claimants to travel to Washington State for treatment. Again, in approximately 4 out of 5 cases, NCM involvement has saved L&I and work injury claimants from the expense and stress of travel to Washington for treatment.

Complex or catastrophic claims

When I say complex or catastrophic claims, I am referring to injuries that result in significant, often irrecoverable, disability. The best example I can give is an injury that results in quadriplegia. Treatment and care for individuals paralyzed by their injuries is incredibly complex. There are so many moving parts from acute treatment to long term treatment. During acute treatment, many families are unsure whether their loved one is even going to survive. Most workers do not have attorneys in these early, but incredibly stressful hours and days. NCM’s can help guide these families to understand the system and make informed decisions.

Families of work injury claimants will bear the load

Once the acute treatment phase has passed, the real work begins. Paralyzed work injury claimants require a team of medical providers resulting in a complex schedule of appointments. Simply managing and getting to appointments is a full-time job. For this, usually a family member must take on the role of a full-time caregiver or a professional caregiver is needed. NCM’s are incredibly skilled in connecting families with the resources they need to determine if they can provide care themselves or need assistance from professionals. A number of other challenges must be addressed as well, including but not limited to: finding appropriate transportation for a paralyzed individual (imagine trying to get a paralyzed individual into a small family sedan), making appropriate home modifications or helping families relocate if needed (imagine trying to bring a paralyzed work injury claimant home to a second floor apartment with no elevator), and obtaining all of the necessary durable medical equipment needed such as wheel chairs, toilet seats, shower accessories, appropriate medical bedding to prevent bed sores, catheters, and the list goes on.

Certainly, if the family elects to hire an attorney, we can help with some of these logistics. Yet, at the end of the day, we are legal professionals. We do not have the knowledge, skill or medical experience to help families with all of the medical logistics needed for a catastrophic injury. I know from personal experience that NCM’s spend countless hours in the early days of claims helping families get everything they need in place. There is no way $200 comes close to compensating NCM’s for the services they provide in this kind of setting.

The role of Nurse Case Managers in L&I claims with other barriers to progress

When I speak of other barriers to progress, I’m generally referring to medical complications that impact claim progress. For example, work injury claimants with underlying health conditions such as diabetes, COPD, pacemakers, thyroid disease, and more may need to coordinate care between specialists and L&I treatment providers before treatment progress can be made. For example, an injured worker with a pacemaker may need clearance from a cardiologist before surgery can be considered. Similarly, work injury clients taking medications for an underlying thyroid disease may now be facing adverse drug interactions for claim related treatments. The list goes on and on.

NCMs are particularly helpful in these situations because they can utilize their medical experience to ensure that appropriate coordinated care is occurring. Another example is when weight loss is needed for treatment progress. For example, medical best practices dictate that people must be under a certain BMI to be eligible for knee replacement surgery. If a work injury claimant needs to lose weight in order to have a particular treatment, then weight loss treatment is covered under the claim. However, only specific methods of weight loss are authorized. NCMs are an invaluable resource in helping work injury claimants find appropriate, authorized weight loss treatment programs, connecting with dieticians, and helping to monitor weight loss progress to ensure it remains on track. Similarly, NCMs are often instrumental in aiding in opioid addiction recovery under the medical treatment guidelines. Again, as attorneys, there are many things we can do to assist work injury claimants with all of these claim related issues. However, at the end of the day, since we are not medical professionals, there are things NCMs can accomplish with more efficiency and experiences than we can.

Cutting funding will have serious negative implications

In summary, claims involving catastrophic work-related injuries not otherwise being managed under the “Catastrophic Project”, work injury claimants that live or have moved out of state and need assistance locating a provider, medically complex condition(s), and or other barriers impacting successful claim resolution are difficult enough as they are. Historically, having access to experienced NCMs has made these challenging claims much more manageable for work injury claimants, their families, attorneys, and L&I alike.

The new fee schedule is going to gut the usefulness of the NCM program. I predict that any savings L&I may see by capping NCM fees at $200 per month will be eclipsed quickly by increased L&I claim costs. I understand the need to avoid excessive hours spent and overbilling, but the 75 hours of service per referral cap already accomplishes that. It is with an unnerving sense of dread for what this will mean for work injury claims that I must unequivocally say: I am incredibly disappointed in L&I. This new Fee Schedule is doing nothing to reduce to a minimum the suffering and economic harm suffered by work injury claimants and their families. In fact, I predict it will do just the opposite.

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