I reviewed the electromyography (EMG) and nerve conduction study. It was abnormal, consistent with cervical radiculopathy involving right C5-C6, bilateral C6-C7, and bilateral C8-T1 nerve roots. The abnormalities on the EMG were consistent with the motor vehicle accident. The MRI of the cervical spine showed disc herniations without adjacent osteophytes at the C3-C4 through C5-C6 levels and at the C7-T1 level. These findings were consistent with the motor vehicle accident.
My current diagnoses are as follows:
• Postconcussion syndrome / mild Traumatic Brain Injury (mTBI)
• Cervical radiculopathy, multilevel, from C-5 through C8-T1, bilateral
• Cervical disc herniations C3-C4 through C5-C6 and C7-T1
Her prognosis is guarded to poor. The above injuries must be considered permanent at this time. The injuries were sustained in the 2012 motor vehicle accident.
It is my opinion that the treatment that the patient received was reasonable and medically necessary for the injuries she sustained. Furthermore it is my opinion that she is definitely going to require additional treatment including treatment for her post-concussion syndrome as outlined by her treating physician, as well as medication for this brain injury. In addition, she is going to require additional treatment for her cervical disc herniations and cervical radiculopathy, including injection therapy and possibly surgery. The conservative cost, exclusive of surgery, would be $5,000 to $10,000 per year.