APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20250053
OBJECTING PARTY: worker
REPRESENTED by: self
RESPONDENT PARTY: employer (not participating)
HEARING: HEARING IN WRITING
HEARD by: S. DiCarlo, appeals resolution officer
ISSUE
The worker objects to the Eligibility Adjudicator’s (EA) decision dated June 24, 2024, that denied initial entitlement for a cerebrospinal fluid (CSF) leak and intracranial hypotension as the EA was unable to establish a causal relation between the injuries and work duties performed by the worker. The decision was reconsidered on September 17, 2024, and remained unchanged.
BACKGROUND
On May 10, 2024, this Detector Dog Handler, for a law enforcement agency, reported to their employer that during their shifts on between April 6-8, 2024, that they attributed the development of a CSF leak which developed into intercranial hypotension. On April 6-7, 2024, the worker was with their K9 inspecting goods and people arriving at the International Airport A, and on April 8, 2024, the worker was conducting K9 training at the border crossing in City A, which they reported involve a high level of physical activity including running, bending, lifting and twisting.
On April 9, 2024, the worker awoke with a severe headache and made an appointment to see their doctor on April 10, 2024. The pain continued and they went to the emergency department and discharged with suspected tension headache. The headache continued and the worker again was seen at the emergency department on April 13, 2024, for treatment of their headache and vomiting.
Medical investigations were conducted, and the worker was diagnosed with intracranial hypotension secondary to a CSF leak. The worker received treatment in the form of blood patches, and following reassessment with their neurologist on June 13, 2024, the worker was cleared for modified work at partial hours.
A decision dated June 24, 2024, determined the date of injury to be April 10, 2024, and denied initial entitlement for a CSF leak and intracranial hypotension as the EA was unable to establish a causal relation between the injuries and work duties performed by the worker.
An Intent to Object (ITO) form was completed on July 26, 2024, objecting to the denial of initial entitlement.
The file was referred to a Physician Consultant via an Occupational Health Assessment Program (OHAP) for a claim consultant assessment for an opinion on whether there is clinical evidence supports the reported mechanism of injury caused the CSF leak and intracranial hypotension. In an OHAP Claim Consult Assessment Final Report, dated September 12, 2024, the Physician Consultant opined that it is conceivable that the work activities as described by the worker could potentially have incited a spontaneous CSF leak and compatibility is possible; however, as the symptoms did not begin suddenly while at work, and everyday non-occupational activities could also have triggered a CSF leak, a causal relationship between the accident history and the development of the CSF leak could not be confirmed.
The Case Manager (CM) conducted a reconsideration on September 17, 2024, and the denial of initial entitlement remained unchanged.
The issue of the denial of CSF leak and intracranial hypotension now forms the basis of this appeal.
AUTHORITY
Workplace Safety and Insurance Act (WSIA), 1997. Section 2, 13, and 43
Operational Policy Manual
Published
Policy 11-01-01 – Adjudicative Process
November 3, 2008
Policy 15-02-01 – Definition of an Accident
October 12, 2004
ANALYSIS
I have carefully considered all the available information, the worker’s submissions, legislation and relevant operational policies in reaching this decision. I find on a balance of probabilities that the worker has initial entitlement for a CSF leak and intracranial hypotension as a result of their Detector Dog Handler duties. The following is my rationale.
An undated submission provided by the worker submitted to the case record on July 26, 2024, positions that the combination of physical strain, sudden movements, potential for minor trauma, and high impact activities associated with working as a police dog handler contributed to the development of a CSF leak, leading to symptoms of intracranial hypotension. The worker positioned that working approximately 40 hours combined on April 6,7 and 8, 2024, along with more than 40 hours of overtime in the month of March 2024 resulted in the spinal dura being at high risk of sustaining a tear during a canine training session on April 8, 2024. The symptoms appeared the morning of April 9, 2024, since a horizontal position, (sleeping the night of April 8, 2024, after the end of their shift at midnight, concealed the headaches as the spinal fluid was able to flow with gravity to the brain). The worker refers to job descriptions provided to the file in support of the physical strain and sudden movements and lifting required in their regular job duties were the contributing cause of the CSF leak which caused the intracranial hypotension.
The worker enclosed a submission on October 10, 2024, and outlined they are seeking reimbursement of 469.58 hours of sick leave from April 9, 2024, to their full return to work on September 1, 2024, which should include reimbursement for missed shift premiums.
The issues to be determined in this appeal is whether the worker has entitlement to the to a CSF leak and intercranial hypotension as a result of their regular work duties as a Detector Dog Handler.
Section 2(1) of the WSIA defines an accident as follows:
A wilful and intention act, not being the act of the worker,
A chance event occasioned by the physical or natural cause, and
Disablement arising out of an in the course of employment.
Policy 15-02-01 titled “Definition of an Accident” further expands on these definitions of an accident. A chance event is defined as an identifiable unintended event which caused an injury. A disablement is defined as a condition that emerges gradually over time, or an unexpected result of working duties.
The reason why it is important to accurately identify the type of accident is because there is a difference in how the decision-maker adjudicates a chance event accident as opposed to a disablement accident.
According to section 13(2) of the Workplace Safety and Insurance Act (WSIA), if the accident arises out of the worker’s employment, it is presumed to have occurred in the course of the employment unless the contrary is shown. If it occurs in the course of the worker’s employment, it is presumed to have arisen out of the employment unless the contrary is shown. However, this presumption only applies to accidents that are deemed a chance event. Based on the evidence before me, I note the worker is claiming a disablement type injury. In a disablement case, there is no presumption of entitlement and therefore the worker must prove that the accident arose both out of and in the course of their employment.
With matters of causation, Tribunal jurisprudence employs the “significant contributing factor” test. Pursuant to that test, in order to be granted benefits, the worker must establish that their pre-injury work duties made a significant contribution to the development of the conditions within their back and brain. It is not necessary that the work activities be the only contributing factor and entitlement may be granted even in situations when there are a number of significant contributing factors, as long as the work activities also contributed significantly to back and brain conditions.
From the outset, I note the EA determined the date of injury to be April 10, 2024, in this case. I make no findings of fact on the date of injury in this case as no arguments have been presented by the worker on this issue.
In considering initial entitlement I refer to Operational Policy 11-01-01 titled “Adjudicative Process” which states that a five (5) point check system is used to adjudicate initial entitlement claims. Each point must be satisfied for initial entitlement to be allowed. There must be an employer; a worker; a personal work-related injury; proof of accident; and compatibility of diagnosis to the accident or disablement history.
The criteria that need to be satisfied in this case, in accordance with Policy 11-01-01, is the fifth criteria, compatibility of the diagnosis to the accident or disablement history.
The Worker’s Report of Injury or Illness (Form 6) was received on May 16, 2024, and completed by the worker and detailed that during the course of their work from April 6-8, 2024, they developed a leak in their cerebral spinal fluid in their thoracic spine and this leak created inter-cranial hypotension. In the three (3) days leading to their symptoms the worker was working their regular duties as a dog handler for a law enforcement agency, inspecting, with their K9, goods and people arriving at International Airport A on April 6 and 7, 2024. On April 8, 2024, the worker reports they were in City A, conducting K9 training exercises until their shift was over the 22:30 (10:30 pm). The worker described the working and training K9’s involves a high level of physical activity including running, bending, lifting and twisting. The morning of April 9th, 2024, the worker woke up with a severe to extreme headache and made an appointment to see their family doctor the next day. On April 10th, 2024, the headache became so severe that the worker went to the emergency department and was discharged with “suspected tension headaches” and was seen again in the emergency department on April 13, 2024, due to the vomiting from the pain. The worker reported the injury as work-related to their employer on May 10, 2024, and indicates that the employer learned the worker sought health care on April 10, 2024, on April 14, 2024.
The Employer’s Report of Injury/Disease (Form 7) completed on May 19, 2024, outlines that the worker injured themselves on April 8, 2024, and that the injury was reported to the employer on May 10, 2024. The employer indicates that the worker received health care for the injury on April 10, 2024, at the emergency department and that they were notified as of April 14, 2024. The employer indicates the worker began to lose time from work as of April 11, 2024. The employer’s knowledge is that the injury occurred on the premises of the Job Site A and was witnessed by another Dog Handler. Section K of the Form 7 details that it is believed that from April 6-8, 2024, the worker developed a leak in their cerebral spinal fluid, suspected to be in the thoracic spine, which created an intracranial hypotension. The employer details the same mechanism of injury as outlined by the worker in the Form 6, and states that the job of working and training a K9 involves a high level of physical activity including: running, bending, lifting and twisting. The employer is not disputing entitlement.
The EA obtained a statement from the worker in memo A0003, which the worker stated they train police dogs. The worker reported completing training exercises with the dogs that involve them to crawl under vehicles, bend and twist and being pulled by 70 pounds (plus) dogs. The worker stated there was no specific incident or trauma but that the next day after training they awoke with an unbearable headache.
The worked was assessed in the emergency department on April 10, 2024, for an assessment of a headache which started 24 hours earlier. The diagnosis was tension headache.
On April 13, 2024, the was reassessed at the emergency department regarding a worsening of the headache associated with vomiting.
A CT scan of the head was conducted on April 13, 2024, and demonstrated no acute abnormalities but did demonstrate slight bulging appearance of the transverse sinuses in addition to the dense appearance can be seen in dural venous sinus thrombosis.
A CT venogram was performed on April 13, 2024, and revealed no evidence of venous thrombosis.
The worker was assessed by a neurologist - Dr. Parker on April 13, 2024, and the consultation report notes no prior history of headaches. Neurological examination was normal, and it was suspected the possibility of intracranial hypotension, spontaneous with no clear preceding trauma, or trigger, as the worker presented with 4-5 days history of positional headache worse when standing up and sitting up. and Dr. Parker ordered an urgent MRI.
An additional medical note dated April 13, 2024, from Dr. Parker outlined due to the worker’s medical condition they would not work until being reassessed which is to occur on April 25, 2024.
An MRI of the brain and spine was conducted on April 19, 2024, outlined subtle bugling/engorgement of the dural venous sinuses noted suggestive intracranial hypotension. Extra thecal fluid collection was noted in the cervical and thoracic spinal canal, most prominent in the posterior thoracic epidural space. Appearance is suggestive of spinal CSF leak. Minimal degenerative changes noted in the lower lumbar spine and a small central L5-S1 disc herniation.
The worker was reassessed on April 25, 2024, and Dr. Parker diagnosed the worker with intracranial hypotension, with an etiology likely spontaneous, given the absence of trauma, lumbar puncture or inciting triggers. The worker was referred for an epidural blood patch, which was performing on April 27, 2024, on the lumbar spine and on May 2, 2024, on the thoracic spine.
On May 9,2024, the worker was reassessed and noted improvement following the thoracic blood patch. Further imaging was ordered to determine the source of the CSF leak, which was suspected to be in the midthoracic spine.
A separate medical note dated May 9, 2024, from Dr. Parker confirmed the worker’s follow up (today) and excused the worker from work until June 13, 2024, due to medical reasons.
A medical note from Dr. Parker dated June 13, 2024, confirmed the worker was seen in neurology and is able to return to their regular duties for half days as of June 17, 2024.
An MRI of the brain and spine taken on June 18, 2024, noted improvement of previously noted abnormal extra thecal fluid collection noted in the cervical and thoracic spine canal. Persistent thin extra-axial fluid collection noted most prominent in the posterior thoracic epidural space and extending to the upper lumbar region.
The OHAP claim consult assessment final report dated September 12, 2024, outlined Dr. Levine’s review of the case record and opinion on whether there is clinical evidence supports the reported mechanism of injured caused the CSF leak and intracranial hypotension. Dr. Levine, referred to medical based literature that “intracranial hypotension caused by CSF leaks can result from tearing of the dural membrane in the spine, rupture of a meningeal diverticulum (which can occur spontaneously or after healing of a dural tear), or CSF-venous distulas. Dural tears can occur spontaneously, as well as after very minor inciting trauma, frequently on a background of degenerative disc disease and or osteophytes…the onset of a CSF leak may be triggered by an inciting event, including a fall, a sudden twist or stretch, sexual intercourse or orgasm, a sudden sneeze, sports activity, or ‘trivial trauma’. These relatively minor events may cause rupture of spinal epidural cysts or perineural cysts or may cause a tear in the dural nerve sheath with resultant cryptic CSF leakage.” Dr. Levine, opined that it is conceivable that the work activities as described by the worker could potentially incited a spontaneous CSF leak and compatibility is possible; however, as the symptoms did not begin suddenly while at work, and everyday non-occupational activities could also have triggered a CSF leak, a causal relationship between the accident history and the development of the CSF leak cannot be confirmed. Dr. Levine indicated that the degenerative changes evident in the lower lumbar spine would not be compatible with the accident history described.
In considering whether compatibility exists between the reported mechanism of and the diagnosis of CSF leak and intracranial hypotension, I note the “Call Letter of Interest” uploaded to the case record July 26, 2024, details duties and expectations for a Detector Dog Handler includes the following:
Handling the dog and providing regular dog training; care and maintenance is integral to the carrying out of these duties.
The duties also require physical effort in training the detector dog, exercising and running with the dog as well as physical strength to control the dog while in search activity.
In addition, I refer to the Hazardous Occurrence Investigation Report, which was uploaded to the case record on July 26, 2024, and was completed by a Superintendent from the law enforcement agency. This report detailed that a disabling injury occurred on April 8, 2024, for the worker who is employed as Detector Dog Handler and has 10 years’ experience in this position. A witness was noted, another Detector Dog Handler in training, and that the direct cause of the injury is related to the repetitive dog training involving bending, lifting, and twisting. For three (3) days prior to the injury the worker was completing detector dog training which involved multiple repetitions. A direct cause of the hazardous occurrence was physical exertion involved in handling a detector dog. Intracranial hypotension caused by suspected CSK leak.
In my review of the case record, I do note that Dr. Parker did not outline in their medical reports a connection to the worker’s work duties performed by the worker to being the cause of their CSF leak and intracranial hypotension; however, I note from Dr. Parker’s initial neurology consultation of April 13, 2024, that the worker works for customs and has been off work due to their inability to being upright. Dr. Parker’s impression included that the worker’s symptoms were most suspicious for intracranial hypotension, “spontaneous, with no clear preceding trauma.” This notion of a “spontaneous” cause is mirrored again in Dr. Parker’s neurology consult of April 25, 2024, when it is outlined that the radiological findings intracranial hypotension, “etiology likely spontaneous, given absence of trauma, lumbar puncture or inciting triggers.” This notion from Dr. Parker, in my view parallels the medical literature outlined by Dr. Levine, that CSF leaks that cause intracranial hypotension can be triggered by an inciting event, including a fall, a sudden twist or stretch, for example which given the activities performed by the worker on April 8, 2024, while dog training would entail repetitive and high physical activity including bending, lifting, twisting, and being pulled by a dog weighing over 70 pounds.
While I acknowledge that Dr. Levine opined the CSF leak cannot be confirmed on the basis that the symptoms did not begin suddenly while at work, I arrive at a different conclusion as the worker’s statement is that they completed their shift of training on April 8, 2024, at 10:30 pm and then went home and slept and awoke with a severe headache the next morning. In my review of the case record, the worker’s statements have not been disputed and have been echoed by the employer’s reporting of the incident via the Form 7 and Hazardous Occurrence Investigation Report. I note no possible other causes of injury has been queried. Medical based literature details common symptoms of a spinal CSF leak are a headache, which the worker had, and that this improves when lying down, which again this has been documented in the emergency neurology reports that the worker’s headache improved when laying down) and that it rarely starts suddenly. On balance, I find the hours of waking up with a severe headache hours after completing a work shift that involved high intensity training with the K9’s is sudden enough to draw a connection to the activities performed by the worker on April 8, 2024, with the onset of symptoms of a severe headache that persisted enough for the worker to go to the emergency department not once but twice in four (4) days.
Dr. Levine, did opine that the worker’s mechanism of injury is compatible with the diagnosis of CSF leak and intracranial hypotension, and I find on a balance of probabilities that the Detector Dog Handler work duties were a significant contributing factor to the onset of symptoms of a severe headache that was subsequently diagnosed as a CSF leak with intracranial hypotension.
I find the fifth criteria of 11-01-01, has been met and the worker has initial entitlement for the conditions of CSF leak with intracranial hypotension.
In considering entitlement to LOE benefits I find Section 43 of the WSIA govern the worker’s entitlement for this issue as Section 43 of the WSIA delineates a worker who has a loss of earnings as a result of the injury is entitled to payment under this section beginning when the loss of earnings begins; however, in this case I remit the issue of entitlement of LOE benefits to the Operating Area for further review and adjudication as while the worker positions in their October 10, 2024, correspondence that they are seeking reimbursement of 469.58 hours of sick leave from April 9, 2024 to their full return to work of September 1, 2024, I note the initial date the worker started losing time varies in this case record as the Form 6 indicates the first day of missed work was April 10, 2024, and the Form 7, indicates the worker began to lose time as of April 11, 2024. The issue of entitlement to LOE benefits flowing from this decision is remitted back to the Operating Area, for further adjudication and is subject to the usual rights of appeal.
CONCLUSION
The worker has initial entitlement for CSF leak and intracranial hypotension. Entitlement to LOE benefits and benefits flowing from this decision is remitted back to the Operating Area for review and adjudication and is subject to the usual rights of appeal.
The objection is allowed.
DATED March 3, 2025
S. DiCarlo
Appeals Resolution Officer
Appeals Services Division