Dr Max E. Ots Aurora BayCare Green Bay, WI

To start off I seen Max Ots in 2009 for the first time with the same back issues I have now. The first thing he dioagnosed me with was 

• April 6, 2009 - artificial disk or a fusion at the L5-Sl level. see notes below.

• 7/15/2019- invasive bilateral SI fusion. Pining the SI joints with three pins drilled thru.  See Max Ots notes below.

• When confronted by email for the Arachnoid Web he missed he said that was not my problem any way. His PA's Medical note is below which shows his PA did look at the T spine MRI and failed to see the T spine arachnoid web.

April 6, 2009

RE:  TERRY

DOB:  

HISTORY OF PRESENT ILLNESS: This is a 54-year-old male seen in consultation today for lower back pain. The patient has had some problems in the past with his back in 1990 but this resolved, and more recently since 2005, he has had this pain. The primary pain is located in the lower back. He does have some radiation to the bilateral groin pain as well as lower extremity pain, which alternates between the right and left leg. The pain is located in the posterior lateral leg and goes into the plantar aspect of the foot into the great toe. He does notice some tingling on and off in the lower extremities and no recent history of weakness. One year ago he had a severe flare-up of this after a massage. At this point, he was started on antiinflammatories, had an MRI of his lumbar spine, and was sent to physical therapy. The therapy aggravated his pain and following this he had an epidural steroid injection on the left at L5-S1. Following this, he did have resolution of all of his pain, which has only recently started to come back. However, apparently after seeing an endocrinologist, his cortisol level dropped and he is not certain that he would want to pursue another injection. He is currently taking Mobic, which he does not take regularly. In the past, he has also tried Diclofenac and Naproxen as well as Valium for his pain. He occasionally takes Oxycodone and Flexeril about once a week when his pain gets quite severe. He has not seen a chiropractor for this issue. He denies any previous injuries or surgeries to his back. He does remark about some neurotoxic chemical exposure while in the Air Force. He does not have any bowel or bladder dysfunction but does note occasional urinary dribbling.

. He is slightly tender to palpation over the lower lumbar spine and surrounding paraspinals. He is nontender over the SI joints and sciatic notches. No pain with internal or external rotation of the hips. Straight leg raise is negative bilaterally. He has ifill strength with hip flexion, knee flexion-extension, dorsi and plantar flexion, and great toe extension. He has frill sensation in all dermatomes in the lower extremities to pinprick testing, patellar, and Achilles. DTRs are 2+14 bilaterally.

IMAGING: MRI of the lumbar spine shows minimal spondylosis and degenerative changes throughout the lumbar spine.

He has no significant disk protrusion or neuroforaminal stenosis. By report, there is a left paracentral annulus tear at L5-Sl.

He does not have any disk degeneration.

IMPRESSION/PLAN: This is a 54-year-old male seen in conjunction with Dr. Ots today for lower back pain. This has been a progressive issue for the patient over the last few years. He has gone through some conservative treatment for this including antiinflammatory medications and epidural steroid injection, which he did not have a good reaction to with the drop in his cortisol level, as well as physical therapy. We recommend that he see a chiropractor for adjustments of the lumbar spine and see how he does with that.

We also recommend that he take the Mobic regularly. I will also refer the patient to Dr. Araujo for further management of his lower back pain. Perhaps the patient could be a candidate for an IDET procedure, but we will let Dr. Araujo decide on this matter. If the patient fails these recommended interventions, he could perhaps be a candidate for an artificial disk or a fusion at the L5-Sl level. An artificial disk would be preferable, however. At this point, no further neurosurgical followup is needed. He will contact our office if he does not improve despite these measures.

lsadora Asman, PA-C

Max E. Ots, MD

IA/MEO/tt4O

#169449

DD: 04/06/09 DT: 04/08/09

Date of visit: 7/15/2019

Reason for Consultation: Terry T Nier was seen on 07/15/19 by Dr. Ots and myself in Neurosurgical consultation at Aurora BayCare Medical Center. He was seen at the request of Paul J Schmitz, MD for evaluation and opinion of bilateral sacroilfltis,

History of Present Illness: Terry I Nier is a 64 year old male patient has a history of chronic mid and low back pain since at least 2003. He’s had bilateral SI joint pain for several years as well. Used to be. Early on the pain was only on the left side, now affects both sides. Pain seems to be worse on the left side. When he lifts his leg he gets shooting pain down the leg will then keep him bed for a couple of days due to the severity. This can occur when going up and down stairs, walking, or lifting his leg in the shower. He also has increased pain when he leans forward. He’s had to significantly cut back on his activities.

He uses an SI belt regularly. He’s had extensive physical therapy through the VA. He is tried chiropractic treatment. He takes hydrocodone. He’s had multiple epidural steroid injections in the lumbar spine, and 3 SI joint injections. The SI injections typically helped for about 2-1/2 months. He also gets steroid injections in his shoulders and elbows, He sees Dr. Koch at prevea spine and Dr. xx through prevea ortho.

Review of Systems:

Positive for: Fatigue, congestion, ear pain, hearing loss, postnasal drip, rhinorrhea, tinnitus, eye itching, apnea, shortness of breath, palpitations, diarrhea, excessive urination, difficulty urinating, urinary incontinence, urinary frequency, urinary urgency, arthralgias, back pain, myalgias, neck pain, environmental allergies, dizziness, headaches, numbness, bruises/bleeds easily, agitation, nervous/anxious, sleep disturbance. Fourteen systems have been reviewed, all are negative aside from positives listed above or otherwise mentioned in HPI or Past Medical History.

Physical Exam:

VITAL SIGNS: Blood pressure 122/78, pulse 68, temperature 97.7 °F (36.5 °C), temperature source Temporal, resp. rate 16, height 5’ S°(1.727 rn), weight 81.6 kg. Body mass index is 27.37 kg/m2. GENERAL:Patient is awake, alert, orientated and in no apparent distress. Mood and affect are appropriate.

HEENT: head normocephalic, atraumatic. Mucosal membranes moist. Cranial nerves grossly intact. Neck is supple.

CARDIOVASCULAR:     regular rate and rhythm. No carotid bruits.

LUNGS: lungs CTA bilaterally

ABDOMEN:   soft, nontender

NEURO: Gait is antalgic. Heel and toe walk are intact. There is no visible deformity or swelling in the back. Back has limited range of motion. Patient is nontender over the lumbar spinous processes, paraspinals, sciatic notches. He is tender over the bilateral SI joints (5/10). No pain with internal/external rotation of the hips. Straight leg raise is negative bilaterally.

Imaging/Diagnostics:

MRI of the lumbar spine from 1/29/19 at St. Mary’s Hospital was reviewed on Mckesson. This demonstrates mild multilevel broad based disc bulge and mild facet arthropathy. There is no significant canal or foraminal stenosis throughout the lumbar spine.

 I hand carried over the disc for my Thoracic spine MRI as I still believed there was an issue in the T Spine. St Vincent Hospital contract radiologist MD Nicholas Kolanko missed it on his report.

"MRI of the thoracic spine on 8/15/18 at St. Vincent Hospital was reviewed on Mckesson. Mild scoliotic curvature in the upper thoracic spine. MRI is otherwise unremarkable." Dr. Max E. Ots totally missed the "Scalpel Sign" on T spine MRI.
Arachnoid WEB or cyst missed. I have to question if Max even looked at the images.

Impression/Plan:

This is a 64 year old year old man seen in conjunction with Dr. Ots for bilateral sacroiliitis, greater on the left than right. Patient has had extensive conservative treatment for this. He has not had any long lasting effects from the therapy or injections. We’ll obtain a CT of the pelvis to check his SI joints. We discussed the possibility of minimally invasive bilateral SI fusion, however ankylosing spondylitis can be considered a relative contraindication to fusing the SI joints, since SI fusion is part of the disease process. However, an autofusion may take several years, during which time the patient is suffering through his pain. He will be send for diagnostic left SI joint injections. If he has good short-term relief of his pain, then he could continue the work up for an SI fusion, and see him back to review everything again with him, and decide is surgery should be considered, Although he has bilateral sacroilitis, he will be initially worked up for the left side,

We discussed that there are no good surgical treatment options to treat his spine pain related to the ankylosing spondylitis.

Isadora E Asman, PA-C

08/21/19

Imaging   Results

MRI LUMBAR SPINE WO CONTRAST (Final result)       Result time 08/21/19 19:39:39

Final result

Impression:

IMPRESSION:

1.   Mild disc bulge L4-LS and minimal disc bulge LS-S1. No significant

central canal or neural foraminal stenosis,

2.   The visualized spinal cord and conus medullaris appears unremarkable.

The results of this exam were called to LAURA L VOGEL-SCHWARTZ on 8/21/2019 7:38 PM.

Narrative:

MRI OF THE LUMBAR SPINE

CLINICAL HISTORY: Radiculopathy, < 6wks, no red flags, no prior management, immunosuppressed, new continence issues. and new pain

TECHNIQUE: Multiplanaç multisequence imaging was obtained of the lumbar spine without contrast.

COMPARISON: None.

FINDINGS:

Curvature and alignment: Normal.

Vertebral body heights: Maintained.

Intervertebral disc spaces: Maintained.

Bone marrow signal: No suspicious focal abnormalities.

Conus medullaris: Negative, terminates at L1 -L2.

Miscellaneous:  Negative.

Terry (MRN:)• Printed at 8/21/19 7:59 PM                        Page 11 of 13

Imaging Results (continued)

T12-L1: Negative.

Li -L2: Negative.

L2-L3: Negative.

L3-L4: Negative.

L4-L5: Mild diffuse disc bulge slightly asymmetric towards the right. Mild facet arthropathy. No significant central canal narrowing. No significant neural foraminal narrowing.

L5-Si: Minimal diffuse disc bulge. No central canal or neural foraminal stenosis.

 Thoracic Spine MRI Scalpel Sign at arrow above. Notice the squished axial cord at the down arrow.

Pretty hard to miss!

You 01/21/2022, 10:31 AM

Dr. Ots your clinic notes on 07-18-2019 say my Thoracic spine MRI was reviewed for abnormalities which may explain my mid to low back pain and your review says unremarkable of the 2018 09 14 T spine (attached and you have the full MRI on file which you can review). My question is: How was this T-spine T5-6 Arachnoid web missed by you? I think I am due an explanation. The radiologist missed it who read the MRI also at St. Vincent Hospital but that is why I came to you for a second opinion. I have scheduled surgery for Feb 10 to remove this arachnoid web and restore normal cfs flow and decompress the cord. Sincerely, Terry 1 attachment 2018 09 14 TERRY MRI SAG STIR IMAGE ARACHNOID WEB WITH NOTES MISSED BY ALL.jpg

Clinical Office Staff 01/21/2022, 11:42 AM Hi Terry, Dr. Ots is out of the office today. This will be reviewed with him upon his return Thanks Corrine RN Clinical Office Staff 01/31/2022, 9:40 AM RE:

Please allow up to 48 hours for a reply. You cannot reply to this conversation. It is too old to be replied to. Green Bay, WI 54313-5827

 Dear Mr. xxxx, I received your note from January 21st of this year. I reviewed your MRI. I do not believe the findings on that MRI explain the symptoms for which I saw you in 2019. At that time it was consistent with sacroiliitis. Sincerely yours, Dictated By: Max E. Ots, MD Signing Provider: Max E. Ots, MD

You 01/31/2022, 3:47 PM With due respect, Your notes clearly state that I had mid back pain along with low back pain since 2003. Why would I have asked for you to look at my Thoracic spine MRI if I only had complaints of low back pain? My thoracic MRI clearly shows that the spinal cord is compressed at T5. Why would you not tell me about that other than you missed it or are not familiar with arachnoid webs on the MRI and I have a history of mid back pain? Attached is the spinal cord compression axial view. No different then when you looked at my MRI in 2019. I think there is a lesson here. A radiologist at Aurora should have looked at the thoracic MRI if you can not see there was an issue with a history of complaints for mid back pain.