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California: Head Contusion’s Effect Makes Pre-Existing Brain Tumor Compensable

October 10, 2023 (8 min read)

By Hon. Susan V. Hamilton, Former Assistant Secretary and Deputy Commissioner, California Workers’ Compensation Appeals Board

Perhaps the title has piqued your curiosity, and you decide to take a second glance. No, you aren’t reading some newsstand tabloid; you are reading LexisNexis Workers’ Compensation eNewsletter. How might a simple head contusion be linked to an anaplastic meningioma so that the brain tumor is found to be compensable? While it is a given that the causation principles underlying California’s workers’ compensation laws require only that an injury be linked in some causal manner to employment to make it compensable (see, Clark v. South Coast Framing, Inc. (2015) 61 Cal. 4th 291, 188 Cal. Rptr. 3d 46, 80 Cal. Comp. Cases 489), such a causal connection doesn’t seem plausible. Au contraire. A recent panel decision provides a thoughtful analysis and discussion that will better inform our understanding of the requisite causal link between the injury and work by a clear example of medical opinion that is substantial evidence. The case is Cecilia Duran v. County of Imperial (September 27, 2023, ADJ14966902).

The Facts

Cecilia Duran (applicant) was employed by the County of Imperial (defendant) as an account clerk. While performing her work duties, a shelf fell, striking applicant’s head and causing a contusion. Injury to the head in the form of a contusion to the scalp was not disputed. Sometime after the injury applicant began experiencing headaches and started feeling a growth on her scalp at the site of the contusion. Applicant was seen by a plastic surgeon who biopsied the growth and diagnosed a cancerous tumor at the location of the scalp contusion.

Applicant was referred to Dr. David Santiago-Dieppa, a neurosurgeon with an enfolded fellowship in endovascular neurosurgery and subspecialty training in vascular, endovascular, and complex cranial issues. Dr. Santiago-Dieppa became applicant’s treating physician. During treatment, defendant asked Dr. Santiago-Dieppa to complete a form regarding whether there was a causal connection between applicant’s brain tumor and her work. Dr. Santiago-Dieppa responded that although the work-related head contusion did not cause applicant’s brain tumor, the inflammatory process following the contusion likely may have expedited the growth and presentation of the tumor. Dr. Santiago-Dieppa was later deposed and confirmed his opinion that the scalp contusion was a causal factor in the rapid growth of the tumor.

Defendant disputed any causal connection between applicant’s brain tumor and the admitted scalp contusion. Dr. Blake Berman was selected as the PQME. Dr. Berman opined that there was no causal relationship between applicant’s scalp contusion and the tumor. A trial was held and the WCJ relied on the expert opinion of Dr. Santiago-Dieppa in finding the brain tumor to be compensable. Defendant sought reconsideration of the decision.

The Panel’s Analysis

The unanimous panel opinion, which also incorporates the WCJ’s Report and Recommendation on Petition for Reconsideration (R&R), jumps right to the heart of the matter—substantial evidence and why it found Dr. Santiago-Dieppa’s opinions to be more persuasive than those of PQME Dr. Berman. The opinion begins with reference to well-settled law that to constitute substantial evidence, a medical opinion must be based on reasonable medical probability (McAllister v. Workmen’s Comp. Appeals Bd. (1968) 69 Cal. 2d 408, 33 Cal. Comp. Cases 660), upon germane facts, upon accurate and adequate history, and must not involve speculation, conjecture or guess (Hegglin v. Workmen’s Comp. Appeals Bd. (1971) 4 Cal. 3d 162, 36 Cal. Comp. Cases 93). It also emphasizes that a medical opinion is only substantial if it sets forth the reasoning behind the opinions given and not just bare conclusions (Granado v. Workmen’s Comp. Appeals Bd. (1970) 69 Cal. 2d 399).

With those principles in mind, the panel’s decision examines the opinions of Dr. Santiago-Dieppa and Dr. Berman. The panel states its agreement with the WCJ that the deposition testimony given by Dr. Santiago-Dieppa is a well-reasoned explanation that supports his opinion that the shelf’s impact upon applicant’s scalp was consistent with his assessment of the growth of the brain tumor and the physical trauma of the impact upon the scalp contributed to and accelerated the growth of the tumor. The panel’s decision includes portions of the verbatim deposition testimony of Dr. Santiago-Dieppa, as follows:

I am a neurosurgeon. I attended medical school at the Johns Hopkins University School of Medicine in Baltimore, Maryland. I completed my neurosurgery residency at the University of California San Diego that included an [sic] enfolded fellowship in endovascular neurosurgery. My subspecialty training within neurosurgery is vascular, endovascular, and complex cranial issues. (App. Exh. 3, David Rafael Santiago-Dieppa M.D., September 13, 2022, deposition transcript, p. 7.)

Q. Okay. Can head trauma impact the growth of those cells and then [sic] result in a tumor?

A. It has been reported in the medical literature.

Q. So are there cases or a case or research that supports a theory that trauma to the head can accelerate that preexisting growth?

A. That has been reported in the medical literature.

(App. Exh. 3, p. 20.)

Q ... So did the falling of the shelf landing on her head, it didn’t cause the tumor, right?

A. It’s my opinion that the trauma did not cause the tumor. It’s my opinion that the shelf striking her head may have caused the rapid growth and presentation that she presented to my clinic with which is in agreement with what has been described in some cases in the literature.

Q. Would you say that the trauma of the shelf falling on her head accelerated the growth of the meningioma?

A. Based off the patient’s history and the case reports in the literature, I would say, that’s medically probable.

Q. So you can state within reasonable medical probability that the shelf falling and landing on her head at work accelerated the meningioma?

A. That is correct.

Q. Okay.· And that acceleration is at least one percent or more; is that accurate? A. That is accurate.

(App. Exh. 3, pp. 22 – 23)

Q. So when you are reaching this conclusion that the head trauma that she suffered at work, specifically the shelf falling and landing on her head, when you reached the conclusion that that trauma accelerated the meningioma within medical probability, what are you basing your opinion on?

A. Two pieces of evidence. Number one, the patient’s history of illness. I found her to be reliable. The patient clearly stated to me that she did not have this lesion prior to the shelf hitting her head and then very soon, within two weeks of the shelf hitting her head, she had rapid and sustained growth. Number two, as has been described in the literature, there are case reports and an association between head trauma and the presentation of these primary extradural meningiomas.

Q. So the mechanism of her injury supports that the tumor’s growth was accelerated?

A. That is correct.

(App. Exh. 3, pp. 23 – 24.)

Q. You said something about the tumor ... extending to the —

A. Extending to the vertex, so the top of the skull. So I would say that the tumor, if I were to classify it, was eccentric to the left but included the top of the head as shown by my radiology colleagues.

Q. And so the shelf either impacting more to the top or the left of her head is consistent with your assessment of the growth of the tumor and that that trauma contributed and accelerated the tumor, correct?

A. That is correct.

(App. Exh. 3, p. 33.)

Next, the panel decision examines Dr. Berman’s response to the deposition testimony of Dr. Santiago-Dieppa as follows:

I previously commented that the patient was diagnosed with an anaplastic meningioma which is a WHO [World Health Organization] grade 3 intracranial/ cranial tumor. This lesion contains anaplastic or essentially pre-malignant cells that can very easily undergo a malignant transformation if not properly treated. The fact that the patient suffered a scalp contusion essentially over the area where the mass had been developing is purely coincidental. The scalp contusion in no way led to this lesion arising or progressing. The fact that the lesion progressed rapidly following the date of injury emphasizes the aggressiveness of this lesion and has virtually nothing to do with the scalp contusion itself. The scalp/skull/dural mass is purely non-industrial. The specific industrial injury suffered by the patient is a scalp contusion which has resolved. (Def. Exh. B, Blake W. Berman, D.O., October 28, 2022, p. 4.)

In comparing the divergent opinions of Dr. Santiago-Dieppa and Dr. Berman, the panel concluded that Dr. Berman used an incorrect legal standard (i.e., “virtually nothing to do with the scalp contusion”) and failed to support his opinion with reference to the medical literature and/or medical case studies. Dr. Santiago’s opinion, on the other hand, was found to be the most persuasive because it was well-reasoned, was based upon an accurate history, was supported by medical literature, and was not the product of conjecture or speculation. That is, of the two diametrically opposed expert opinions, the panel concurred with the WCJ’s assessment that Dr. Santiago-Dieppa’s opinions constituted substantial evidence.

What’s the Big Deal

The requirement that medical opinions be supported by substantial evidence is not a new concept. It is well understood. Nonetheless, there are many instances in which expert medical opinion falls short of that standard, especially in disputes over causation. This case is a helpful illustration of that point. Through the 10 deposition questions set forth above, Dr. Santiago-Dieppa demonstrates understanding of the appropriate legal standard of causation, knowledge of all pertinent facts concerning applicant’s injury and the development of the tumor along the site of the contusion, and is able to state that consistent with the medical literature, the mechanism of applicant’s injury supports his opinion that her brain tumor’s growth was accelerated by the impact to the scalp.

Reminder: Board panel decisions are not binding precedent.

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