Wyatt v. Haldex Hydraulics

NO. COA14-335

NORTH CAROLINA COURT OF APPEALS

Filed: 2 December 2014

MAYFORD WYATT,
Plaintiff,

v. From North Carolina Industrial
Commission
I.C. No. W06970
HALDEX HYDRAULICS, Employer,
and SENTRY INSURANCE, Carrier,
Defendants.

Appeal by Defendants from opinion and award entered 10

January 2014 by the North Carolina Industrial Commission. Heard

in the Court of Appeals 10 September 2014.

Pressly, Thomas & Conley, PA, by Edwin A. Pressly, for
Plaintiff.

Hill Evans Jordan & Beatty, PLLC, by Richard T. Granowsky,
for Defendants.

STEPHENS, Judge.

Employer Haldex Hydraulics and its insurer Sentry Insurance

(collectively, “Defendants”) appeal from an opinion and award of

the full North Carolina Industrial Commission (“the Commission”)

filed 10 January 2014. The Commission’s opinion and award

affirmed an opinion and award by Deputy Commissioner Keischa M.

Lovelace, filed 13 May 2013, which had determined that Plaintiff
 -2-
Mayford Wyatt sustained compensable injuries to his brain and

spine as a result of a workplace lifting accident on 31 October

2008. We affirm.

Background

The evidence before the Commission tended to show that

Plaintiff began working at Defendant’s Statesville plant in

1988, where he was employed as a CNC Setup Operator and was

cross-trained on the operation of several different machines

used by Defendant to produce hydraulic gear pumps and

transmissions for companies such as John Deere and Caterpiller.

On 31 October 2008, Plaintiff and a co-worker were

conducting inventory, counting aluminum parts stored in metal

tubs on metal shelves. To remove the tubs, Plaintiff first slid

them off the shelves, which were coated with an oil film from

the gear manufacturing process, then his co-worker grabbed the

front handle while Plaintiff twisted his body to the left and

reached into the shelf with his right arm to grab the other

handle. The two men then placed the tubs on the floor, counted

and labeled and replaced the parts, and returned the tubs to the

shelves. Plaintiff was injured when he attempted to remove a

mislabeled tub that contained parts made of a material much

heavier than aluminum: instead of an expected weight of 60 to 70
 -3-
pounds, the tub weighed approximately 280 pounds. As his co-

worker grabbed the front handle, Plaintiff balanced on one knee

holding the back handle, then twisted and turned with the tub

and fell to the floor with it. Plaintiff was taken to the

Iredell Memorial Hospital emergency room twice that day due to

pain in his lower back. As a result of his injuries, Plaintiff

was out of work from 31 October 2008 through 11 December 2008.

Defendants accepted the compensability of Plaintiff’s low back

condition pursuant to a Form 60.

On 9 December 2008, Plaintiff’s primary care physician, Dr.

Daniel Bellingham, assessed Plaintiff with right L3-4 nerve root

impingement and referred him to a spine surgeon for

consultation. Shortly thereafter, Plaintiff was permitted to

return to work with light duty restrictions of no lifting over

25 pounds, limited bending and twisting, and no stooping or

squatting. Plaintiff received ongoing treatment at

OrthoCarolina, and eventually orthopedic surgeon Dr. Theodore

Belanger diagnosed Plaintiff’s low back condition as lumbar

stenosis with persistent back and right leg pain, numbness, and

weakness, which did not require surgical intervention. In

December 2009, Plaintiff submitted a Form 25R Evaluation for

Permanent Impairment. On 25 January 2010, the Industrial
 -4-
Commission approved a Form 26A, Employer’s Admission of

Employee’s Right to Permanent Partial Disability Compensation,

awarding Plaintiff $12,932.32 for a permanent partial impairment

rating of 7.5% as a result of his low back injury.

Throughout the treatment of his low back condition in 2009

and 2010, Plaintiff also complained of seemingly unrelated

symptoms that began almost immediately after his 31 October 2008

accident, including dizziness, loss of balance, nausea, stuffy

ears, sinus pressure, fatigue, insomnia, severe headaches, and

episodic numbness in his face, tongue, torso, and limbs. During

the two months he was unable to work in late 2008, Plaintiff’s

family noticed that he remained in bed and slept most of the

time, experienced difficulty walking and balancing, could not

keep his car on the road as he was unable to apply steady

pressure to the gas pedal, frequently dozed off mid-sentence

during conversations, and had difficulty understanding,

prompting his relatives to explain things to him in an

“elementary way.” Previously an active church member who

regularly attended services on Wednesday and twice on Sunday,

Plaintiff did not attend church for almost two months. When he

returned in December 2008, church members noticed an observable

decline in his health. Plaintiff had trouble maintaining his
 -5-
balance, dragged his foot when walking, had difficulty hearing,

and fell into a deep sleep during services and conversations.

Upon his return to work, Plaintiff’s co-workers observed a

noticeable decline in his physical abilities: Plaintiff

regularly slept at his work station, walked slowly, and appeared

to drag one of his legs while walking. Other machine operators

had to be assigned to perform Plaintiff’s lifting tasks, and his

team leader noticed he had trouble understanding directions and

suffered from balance issues.

Plaintiff’s doctors offered multiple diagnoses, including

sinusitis and sleep apnea, but his symptoms persisted, and in

March 2010 he was referred for a neurological consult after an

MRI of his brain showed a herniated cerebellar tonsil consistent

with a Chiari malformation. A Chiari malformation is a condition

at the junction of the neck and skull that causes compression of

the part of the central nervous system where the spine joins the

brain. There are two types of Chiari malformation: congenital

Chiari malformations occur from a person’s congenital cranium

formation, whereas acquired Chiari malformations can develop

through intracranial hypotension, which is a cerebrospinal fluid

(“CSF”) balance issue between the brain and the spine that can

be caused by lifting injuries resulting in cerebrospinal fluid
 -6-
leaks. Chiari malformations can result in a condition known as

“brain sag.” Typically, the brain is supported within the skull

and spinal column by cerebral spinal fluid, but when spinal

fluid is at a lower pressure underneath the brain, the brain

tends to sag down towards the base of the skull. Classic

symptoms of a Chiari malformation include severe headache

associated with coughing, problems with balance, dizziness,

difficulty walking, and cranial nerve dysfunction which can

cause facial symptoms, tongue numbness, and balance and

swallowing difficulties. However, symptoms indicative of Chiari

malformations are also suggestive of other medical conditions

unrelated to the brain, cervical spine compression, and other

neurological abnormalities, and it is not uncommon for a person

to exhibit symptoms of a Chiari malformation over an extended

period of time before diagnosis.

On 18 March 2010, Plaintiff sought treatment with Dr. John

Wilson, a board-certified expert in neurological surgery. While

certain aspects of Dr. Wilson’s examination were indicative of

Chiari malformation, other aspects suggested a problem further

down Plaintiff’s cervical spine. A subsequent cervical MRI

showed significant stenosis with cord signal changes, so Dr.

Wilson performed an anterior cervical discectomy, decompression,
 -7-
and fusion on 16 April 2010. At his follow-up appointment on 20

May 2010, Plaintiff reported complete resolution of his

symptoms, which surprised Dr. Wilson, who had anticipated

needing to perform a Chiari decompression to alleviate

Plaintiff’s symptoms. However, on 26 August 2010, Plaintiff

returned to Dr. Wilson with complaints of dizziness, difficulty

balancing, facial numbness, bowel control issues, and “things

not tasting good.” On 12 October 2010, Plaintiff complained of

the same symptoms, as well as hearing problems, decreased

sensation on his right side, and double vision. On 1 November

2010, Dr. Wilson performed two surgical procedures on Plaintiff:

a Chiari decompression and a C3 laminectomy with C2-C5 fusion.

At a follow-up appointment on 16 December 2010, Plaintiff

reported some improvement in his dizziness but complained of

persistent balance difficulties, as well as hand-to-eye

coordination issues, hearing “echoes,” and falling asleep while

driving.

On 4 February 2011, Plaintiff was taken to the Iredell

Memorial Hospital emergency room suffering from quadriparesis

and then immediately transferred to Wake Forest Baptist Hospital

for assessment of a neurological emergency. Dr. Thomas Sweasey,

a board-certified expert in neurosurgery and neurocritical care,
 -8-
was the neurosurgeon on call and determined after reviewing an

MRI that Plaintiff needed surgery to treat cervical spondylosis,

severe canal stenosis, and significant spinal cord impingement

with evidence of cord signal change. Dr. Sweasey performed a

posterior cervical decompression and fusion. Although Plaintiff

recovered from his quadriparesis, his MRIs indicated he suffered

from “brain sag,” and Dr. Sweasey subsequently assumed

responsibility for Plaintiff’s care as his treating physician.

Between 15 March 2011 and 27 October 2011, Plaintiff was

hospitalized four times complaining of extreme somnolence,

frontal headaches, trouble balancing and walking, dizziness,

hearing loss, slurred speech, memory and comprehension issues,

and bladder control problems. At Dr. Sweasey’s direction,

Plaintiff underwent an array of different diagnostic tests and

assessments——including lumbar punctures, a ventricular

peritoneal shunt, and two cranioplasty procedures on the back

part of his skull——to determine the cause of his “brain sag” and

the best options for treatment. Dr. Sweasey consulted with

several specialists, including Dr. Thomas Ellis, co-director of

the Deep Brain Stimulation Program at Wake Forest, who noted

that, although Plaintiff’s “presentation is somewhat difficult

to truly classify as one diagnosis,” his symptoms were “most
 -9-
convincing for communicating hydrocephalus as he has significant

brain sag.” However, after extensive interviews with Plaintiff

and his family regarding his medical history and the onset and

progression of his symptoms, Dr. Sweasey eventually diagnosed

Plaintiff with cervical cord compression and an acquired Chiari

malformation caused by intracranial hypotension.

Plaintiff continued to work for Haldex Hydraulics between

11 December 2008 and 15 April 2010. On 11 February 2010,

Plaintiff suffered a fall while working. He received treatment

at an urgent care office for his back and hip, but did not miss

any work due to the fall. On 13 April 2010, Plaintiff gave

written notice to Defendant that he wished to enter a severance

agreement to begin following his short-term disability leave,

which ran from 23 April 2010 through the week ending 29 May

2010. On 4 June 2010, Plaintiff signed a severance agreement,

release, and waiver, indicating that his employment with

Defendant terminated 28 May 2010.

Procedural History

On or about 1 July 2010, Plaintiff filed a Form 18 Notice

of Accident to Employer and Claim of Employee, Representative,

or Dependent with the Commission, alleging injuries to his back,

neck, and leg sustained from his 31 October 2008 accident.
 -10-
Plaintiff subsequently filed a Notice of Change of Condition on

28 June 2011. On 14 February 2012, Plaintiff’s wife filed a Form

42 Application for Appointment of Guardian Ad Litem, which the

Commission ultimately approved, because of Plaintiff’s

difficulties with his hearing, reasoning, and memory. She also

averred that she felt it was unsafe to leave Plaintiff alone. On

5 March 2012, Plaintiff filed a Form 33 Request for Hearing and

on 26 March 2012, Plaintiff filed an Amended Form 33 stating

that his injuries were to his back, neck, and brain. Defendants

responded and denied compensability for Plaintiff’s cervical and

cognitive problems. Deputy Commissioner Lovelace heard the

matter on 10 August 2012 and issued an opinion and award

concluding that Plaintiff’s intracranial hypotension, Chiari

malformation, and cervical spine conditions were causally

connected to his 31 October 2008 work-related injury; that

Plaintiff was disabled from working; and that he was entitled to

indemnity and medical compensation. Defendants timely appealed

the opinion and award to the full Commission on 16 May 2013.

The Full Commission heard the matter on 25 October 2013 and

issued an opinion and award on 10 January 2014 affirming Deputy

Commissioner Lovelace’s opinion and award with minor

modifications, over a dissent without written opinion from
 -11-
Chairman Andrew T. Heath. During the course of its hearing into

the causation and compensability of Plaintiff’s brain and

cervical spine injuries, the Commission reviewed depositions

taken from Dr. Bellingham, Dr. Belanger, Dr. Wilson, and Dr.

Sweasey.

Dr. Bellingham, Plaintiff’s primary care physician, did not

render an opinion regarding the causal relationship between

Plaintiff’s cervical and brain conditions and the 31 October

2008 workplace lifting accident, but testified that he did not

expect Plaintiff’s condition to improve, stating “we can always

hold out hope, but he hasn’t made a lot of change for quite some

time.”

Dr. Belanger, an orthopedic surgeon who treated only

Plaintiff’s low back condition, agreed with the Chiari

malformation diagnosis but opined within a reasonable degree of

medical certainty that it was a congenital, rather than

acquired, condition and that he therefore did “not see how a

single lifting injury of any sort could cause or contribute in

any material way to []Chiari malformation, which is a congenital

anomaly present since birth.” Dr. Belanger also opined to a

reasonable degree of medical certainty that Plaintiff’s cervical

spine condition was due to degenerative cervical spondylosis and
 -12-
therefore not caused by any particular event or injury,

including the 31 October 2008 accident, although he did

acknowledge it was possible that an acute event could exacerbate

or aggravate Plaintiff’s underlying condition. However, the

Commission assigned little weight to Dr. Belanger’s expert

opinion, given that Dr. Belanger did not treat Plaintiff for

either his cervical spine or his brain condition, and further

admitted that only 10 to 15 of the 2,000 to 3,000 patients he

treats annually need treatment for symptomatic Chiari

malformations, and he typically refers those patients to

neurosurgeons.

Dr. Wilson confined his expert opinion to the conditions

for which he treated Plaintiff between March and December 2010.

He testified that while certain aspects of his examination

indicated a Chiari malformation, Plaintiff was not experiencing

brain sag at the time of his treatment, and therefore Dr. Wilson

would not give a causative opinion regarding Plaintiff’s brain

sag, although he did note that it may have subsequently

developed as a consequence of the Chiari decompression procedure

he performed. Further, Dr. Wilson testified that it was

plausible for a lifting injury to cause brain sag, although that

was not something he considered in his evaluation of Plaintiff.
 -13-
While Dr. Wilson would not give an opinion regarding an acquired

Chiari malformation caused by intracranial hypotension, he

explained that it could occur

if a person during the course of some kind
of injury or heavy lifting . . . developed a
spontaneous CSF leak somewhere in their
spinal column, and so the CSF is leaking and
they develop spontaneous intracranial
hypotension, the brain sags, the cerebellar
tonsils descend, [and] that is
hypothetically a possible way you can
develop this kind of tonsillar descent.

Regarding Plaintiff’s cervical spine condition, Dr. Wilson

opined that although a Chiari malformation can cause cervical

cord compression, Plaintiff’s condition was not causally related

to his 31 October 2008 workplace lifting accident, but was

instead the result of degenerative cervical spondylosis, which

Plaintiff’s lifting injury did not exacerbate.

Dr. Sweasey diagnosed Plaintiff with acquired Chiari

malformation and opined to a reasonable degree of medical

certainty that the most likely cause was intracranial

hypotension, of which the most likely proximate cause was a

spinal fluid leak secondary to Plaintiff’s 31 October workplace

lifting injury. Dr. Sweasey’s opinion was based upon the

significant amount of time he spent conducting tests and

discussing Plaintiff’s case with other specialists, as well as
 -14-
Plaintiff and his family. Dr. Sweasey further opined that

Plaintiff’s temporary improvement following the procedures Dr.

Wilson performed in April and November 2010 was indicative of

intracranial hypotension, explaining that more likely than not,

every time Plaintiff’s spine is manipulated during a surgical

procedure, pressure is left on the thecal sac because there is

some blood left behind, and Plaintiff’s condition improves

dramatically as the blood helps support the brain. The

improvement, however, is temporary as Plaintiff’s condition

worsens as the blood is absorbed by the surrounding tissue. Dr.

Sweasey also testified that the cause of Plaintiff’s Chiari

malformation was unknown during Dr. Wilson’s treatment because,

he explained, Plaintiff was in a very small group of people

“where the mechanism they acquire, the [C]hiari malformation is

decreased pressure which allows the brain to sag and the

cerebellum to sag through the foramen magnum, which then causes

them to be symptomatic.” Regarding Plaintiff’s cervical cord

compression, Dr. Sweasey opined that more likely than not

Plaintiff’s condition resulted from an aggravation of an

underlying cervical condition sustained during his 31 October

2008 workplace injury. As Dr. Sweasey explained, consistent with

Plaintiff’s gradual onset of symptoms, a person may have spinal
 -15-
cord compression and irritation without initially experiencing

pain but then slowly develop a deficit over time. Dr. Sweasey

further opined that, more likely than not, Plaintiff’s cervical

spine issue is related to leakage of spinal fluid from a nerve

root with the fluid absorbed by the surrounding tissue. Finally,

Dr. Sweasey opined that, more likely than not, Plaintiff will

not be able to maintain gainful employment on a permanent basis

as a result of his injuries.

Ultimately, the Commission assigned the most weight to Dr.

Sweasey’s expert opinion. As the Commission explained in its

conclusions of law:

The greater weight of the medical evidence
showed that symptomatic [C]hiari
malformations, whether congenital or
acquired, are rare conditions that are
treated by neurosurgeons. Both neurosurgeons
who treated Plaintiff diagnosed Plaintiff
with a [C]hiari malformation. As stated in
the findings of fact, the Full Commission
assigned greater weight to the expert
opinion of Dr. Sweasey than Dr. Wilson[,] as
Dr. Wilson limited his expert opinion to his
treatment time period and did not consider
the effect of the extensive medical
treatment, testing, and specialist
consultations that occurred subsequent to
Dr. Wilson’s treatment of Plaintiff. In
contrast, Dr. Sweasey consulted numerous
specialists, conducted a variety of
diagnostic tests, interviewed Plaintiff and
his family extensively[,] and reviewed
Plaintiff’s voluminous medical records to
determine Plaintiff’s diagnosis, treatment
 -16-
modalities, and the cause of Plaintiff’s
condition. Dr. Sweasey’s expert opinion is
legally sufficient to establish a causal
connection between Plaintiff’s intracranial
hypotension and cervical spine condition to
his work-related injury.

Thus, based on a preponderance of the evidence of record, the

Commission found as facts that, as a result of his 31 October

2008 workplace lifting injury, “Plaintiff sustained an

intracranial hypotension that caused an acquired [C]hiari

malformation, or brain sag” and also that “Plaintiff sustained

an exacerbation or aggravation of his underlying and pre-

existing cervical spondylosis resulting in cervical stenosis,

cervical cord compression, and other causally related

conditions.”

The Commission also concluded that Plaintiff’s claim was

timely filed and that Plaintiff had met his burden of proof to

show he was incapable of earning pre-injury wages in either the

same or any other employment and that the incapacity to earn

pre-injury wages was caused by Plaintiff’s injury, given Dr.

Sweasey’s testimony that more likely than not, Plaintiff will

not be able to return to gainful employment in the future due to

his acquired Chiari malformation caused by intracranial

hypotension. Therefore, the Commission concluded that “Plaintiff

is entitled to have Defendants pay for all related medical
 -17-
expenses incurred or to be incurred that are necessary and

reasonable treatment that would effect a cure, give relief or

lessen Plaintiff’s period of disability” and further ordered

that Defendants pay Plaintiff $663.35 per week in temporary

total disability compensation, dating back to 1 November 2010

and continuing until Plaintiff can return to work. Defendants

gave timely notice of their intent to appeal the Commission’s

opinion and award pursuant to N.C. Gen. Stat. § 97-86.

Standard of Review

This Court’s review of an opinion and award by the

Commission is limited to two inquiries: (1) whether there is any

competent evidence in the record to support the Commission's

findings of fact; and (2) whether the Commission’s conclusions

of law are justified by the findings of fact. See Deese v.

Champion Int’l Corp., 352 N.C. 109, 116, 530 S.E.2d 549, 553

(2000). The Commission's conclusions of law are reviewable de

novo. See Whitfield v. Lab. Corp. of Am., 158 N.C. App. 341,

348, 581 S.E.2d 778, 783 (2003) (citation omitted). As for the

Commission’s findings of fact, if supported by competent

evidence, they are conclusive even if the evidence might also

support contrary findings. Jones v. Candler Mobile Village, 118

N.C. App. 719, 721, 457 S.E.2d 315, 317 (1995) (citation
 -18-
omitted). Indeed, the Commission is “the sole judge of the

credibility of the witnesses and the weight to be given their

testimony.” Adams v. AVX Corp., 349 N.C. 676, 680, 509 S.E.2d

411, 413 (1998) (citation omitted). On appeal, this Court “does

not have the right to weigh the evidence and decide the issue on

the basis of its weight” because our duty “goes no further than

to determine whether the record contains any evidence tending to

support the finding.” Anderson v. Lincoln Constr. Co., 265 N.C.

431, 434, 144 S.E.2d 272, 274 (1965) (citation omitted).

Causation of Plaintiff’s Brain Condition

Defendants first argue that the Commission erred in

concluding Dr. Sweasey’s expert medical testimony was legally

sufficient to establish a causal connection between Plaintiff’s

brain condition and his work-related lifting accident on 31

October 2008. Specifically, Defendants contend that Dr.

Sweasey’s opinion does not constitute competent evidence to

support the Commission’s causation determination because Dr.

Sweasey could not definitively confirm the existence of the

cerebrospinal fluid leak that he testified caused Plaintiff’s

intracranial hypotension which in turn resulted in Plaintiff’s

brain sag. Thus, Defendants claim Dr. Sweasey’s opinion was

based merely upon speculation and conjecture, which, based on
 -19-
our Supreme Court’s decision in Young v. Hickory Bus. Furniture,

353 N.C. 227, 538 S.E.2d 912 (2000), Defendants insist is “not

sufficiently reliable to qualify as competent evidence on issues

of medical causation.” Id. at 230, 538 S.E.2d at 915. Therefore,

Defendants argue that the Commission erred in concluding

Plaintiff’s brain condition was caused by his work accident and

compensable under the Workers’ Compensation Act. We disagree.

In Young, our Supreme Court reversed this Court’s opinion

affirming an award of the Commission due to a complete lack of

competent evidence to support the Commission’s findings of fact—

—that the plaintiff’s fibromyalgia was caused by a work-related

accident——because the medical causation testimony the Commission

relied upon was based entirely on one expert’s speculation and

conjecture. Id. at 231, 538 S.E.2d at 915. A careful review of

that expert’s testimony revealed that he considered fibromyalgia

to be “an illness or condition of unknown etiology” and that he

“frequently could not ascribe a cause for fibromyalgia in his

patients.” Id. Moreover, the expert admitted there were at least

three alternative potential causes for the plaintiff’s condition

but that he had performed no tests to rule them out, although he

did acknowledge that additional tests “need[ed] to have been

done.” Id. Instead, his diagnosis relied entirely upon the post
 -20-
hoc ergo propter hoc fallacy, given his testimony that, “I think

that she does have fibromyalgia and I relate it to the accident

primarily because, as I noted, it was not there before and she

developed it afterwards. And that’s the only piece of

information that relates the two.” Id. at 232, 538 S.E.2d at

916. The Court ultimately concluded that because the expert’s

testimony “demonstrate[ed] his inability to express an opinion

to any degree of medical certainty” as to causation and was

based “solely on supposition and conjecture,” it was incompetent

and insufficient to support the Commission’s findings of fact.

Id. at 233, 538 S.E.2d at 917.

In the present case, Defendants contend Dr. Sweasey’s

testimony reveals that his medical causation opinion is founded

solely on speculation and conjecture, and is thus analogous to

the expert opinion rejected as incompetent in Young.

Specifically, Defendants point to Dr. Sweasey’s testimony that

“we don’t have any documentation of [a cerebrospinal fluid

leak]” when he was asked how he reached his opinion that

Plaintiff’s condition was caused by intracranial hypotension

resulting from the workplace accident. Additionally, Defendants

emphasize that Dr. Sweasey acknowledged there are multiple

mechanisms by which a person can acquire intracranial
 -21-
hypotension, but was unable to state the percentage of cases in

which the event causing the condition was ultimately identified,

and did not testify to any diagnostic testing or other actions

that he took to rule out other potential causes.

However, the full context of Dr. Sweasey’s testimony

demonstrates that locating a cerebrospinal fluid leak was just

one of “three different pathways” by which Dr. Sweasey could

have arrived at his intracranial hypotension diagnosis. Dr.

Sweasey went on to explain that his diagnosis was more informed

by the nature and sequence of Plaintiff’s symptoms and

Plaintiff’s responses to various tests, treatments, and surgical

procedures. Notably, Dr. Sweasey testified that the fact

Plaintiff’s symptoms improve when he is placed in a supine

position “suggests that there is a pressure differential inside

of his head that allows the sag to occur when he’s upright,” and

that Plaintiff’s dramatic temporary improvement immediately

following an epidural blood patch——which Dr. Sweasey testified

is a “common treatment for spinal fluid leaks”——and two

cranioplasties further confirmed that Plaintiff suffered from

intracranial hypotension, “the most likely proximate cause of

[which] was a spinal fluid leak secondary to his injury.”
 -22-
Defendants also contend that Dr. Sweasey’s opinion is based

merely upon speculation because his testimony established that

there is no scientific basis for working backwards in time to

connect Plaintiff’s brain sag to his 31 October 2008 injury.

Specifically, Defendants highlight Dr. Sweasey’s testimony, when

asked how to pinpoint precisely how long it takes for brain sag

to develop after intracranial hypotension, that

I don’t think we have enough cases in our
literature to say, you know, how long that
is going to take. I’m sure it could be very
immediate in some individuals. I’m sure it
could take days in some. I’m sure it could
take longer in others. But I don’t have any
way of proving that at this point in time.

Defendants’ argument fails to persuade us. Rather than proving

his causation opinion “is of no more value than a layman’s

opinion,” as Defendants insist based on Young, a careful review

of the transcript of Dr. Sweasey’s testimony makes clear that

his point was that because the medical literature is still

evolving and different patients experience the onset of their

symptoms at different times, that makes close observation of

each individual patient’s history and reactions to treatment all

the more crucial. And here, unlike the expert in Young, Dr.

Sweasey spent months consulting with numerous specialists,

conducting a variety of diagnostic tests and extensive
 -23-
interviews with Plaintiff and his family, and reviewing

Plaintiff’s voluminous medical records to determine his

diagnosis, treatment modalities, and the cause of Plaintiff’s

condition, which is why the Commission ultimately found his

causation opinion most persuasive.

Defendants further attempt to undermine Dr. Sweasey’s

causation opinion by contrasting it with Dr. Wilson’s testimony.

As Defendants emphasize, Dr. Wilson testified that the onset of

brain sag and Chiari malformation are not typically associated

with traumatic injuries, but can develop in response to Chiari

decompression surgeries like the one he performed on Plaintiff

on 1 November 2010. Indeed, Defendants argue that there is no

competent evidence indicating Plaintiff suffered from

intracranial hypotension-induced brain sag prior to Dr. Wilson

performing the Chiari decompression. However, this argument

ignores several of the Commission’s findings of fact which,

because Defendants do not challenge them, are presumed

conclusive. First, testimony from Plaintiff’s family, co-

workers, and fellow church members describes Plaintiff suffering

from symptoms of Chiari malformation and brain sag beginning in

the weeks and months immediately following his 31 October 2008

accident. Plaintiff saw multiple physicians for treatment of
 -24-
these symptoms, but it took over a year before he was referred

to a neurologist, which is in keeping with the Commission’s

finding that symptoms indicative of Chiari malformations are

also suggestive of other medical conditions unrelated to the

brain, cervical spine compression, and other neurological

abnormalities, and it is not uncommon for a person to exhibit

symptoms of a Chiari malformation over an extended period of

time before a correct diagnosis is reached. Finally, Defendants

ignore Dr. Wilson’s own testimony that it is indeed

hypothetically plausible for a lifting injury to cause brain

sag. While Dr. Wilson would not give an opinion regarding an

acquired Chiari malformation caused by intracranial hypotension

because it was not something he considered in evaluating

Plaintiff’s condition, he explained that it could occur

if a person during the course of some kind
of injury or heavy lifting . . . developed a
spontaneous CSF leak somewhere in their
spinal column, and so the CSF is leaking and
they develop spontaneous intracranial
hypotension, the brain sags, the cerebellar
tonsils descend, [and] that is
hypothetically a possible way you can
develop this kind of tonsillar descent.

In light of Dr. Sweasey’s testimony and the rest of the

evidence of record, we conclude Defendant’s objections regarding

Dr. Sweasey’s inability to pinpoint the exact source of
 -25-
Plaintiff’s intracranial hypotension go more to the weight of

his opinion than its competence. Indeed, despite their claim

that Dr. Sweasey’s causation opinion is mere speculation, the

majority of Defendants’ argument reads more like an invitation

for this Court to reweigh the evidence that was presented before

the Commission. We recognize that Defendants presented

substantial evidence that would have supported a contrary

determination regarding the cause of Plaintiff’s brain

condition. But as our prior cases make clear, it is not this

Court’s place or prerogative to second-guess the Commission’s

credibility determinations so long as its findings of fact are

supported by competent evidence. See Adams, 349 N.C. at 680, 509

S.E.2d at 413. Because we do not agree with Defendants’

contention that Dr. Sweasey’s opinion was so speculative as to

render it incompetent, we hold the Commission did not err in

concluding that his causation opinion was legally sufficient to

support its determination that Plaintiff’s injury was, in fact,

compensable under our State’s Workers’ Compensation Act.

Aggravation of Plaintiff’s Cervical Spine Condition

Defendants next argue that the Commission erred in

concluding that Dr. Sweasey’s causation opinion was legally

sufficient to establish that Plaintiff’s 31 October 2008 lifting
 -26-
injury caused an exacerbation or aggravation of his underlying

and pre-existing cervical spine condition. We disagree.

As indicated in the Commission’s findings of fact:

Dr. Sweasey opined that more likely than
not, Plaintiff’s cervical cord compression
for which he underwent surgery on April 16,
2010 and November 1, 2010 resulted from an
October 31, 2008 aggravation of an
underlying cervical condition. Dr. Sweasey
explained that symptom onset was subtle and
did not become apparent until over time. A
person may have spinal cord compression and
spinal cord irritation for which a person
does not feel pain, but slowly over time the
person develops a deficit. Dr. Sweasey also
stated that more likely than not,
Plaintiff’s cervical spine issue is related
to leakage of spinal fluid from a nerve root
with the fluid absorbed by the surrounding
tissue.

Here again, Defendants challenge the Commission’s findings based

on their prior argument that Dr. Sweasey’s causation opinion was

too speculative to be considered competent under Young and

demonstrates his reliance on the post hoc, ergo propter hoc

fallacy. To support their claim, Defendants highlight Dr.

Sweasey’s testimony that,

basically looking backwards, and trying to
find what I considered the common thread
through the whole picture, you know,
original spinal surgery, Chiari
decompression, subsequent spine surgery,
subsequent shunt, subsequent cranioplasty of
two different forms, epidural blood patches,
the common thread when I look back through
 -27-
all of that appears to be intracranial
hypotension secondary to the lifting injury,
and more likely than not the problem that we
discussed as far as a leakage of spinal
fluid from a nerve root.

The spine issue in the cervical spine . . .
appears to have a relationship to that, too.
So that’s why I label that as likely——more
likely than not being related to the lifting
injury, also. Again, it’s my opinion.
Finding an actual absolute perfect thread
for that one is harder, but I think
certainly, you know, I would base my
opinions and everything more on the
intracranial hypotension issue. And I think
that fits better with his picture all the
way through.

Defendants repeat their allegations that Dr. Sweasey’s testimony

is incompetent because it failed to pinpoint the location of

Plaintiff’s cerebrospinal fluid leak and there is no scientific

basis for working backwards from Plaintiff’s cervical spine

condition to his 31 October 2008 injury. However, as already

discussed, these objections go more to the weight of Dr.

Sweasey’s opinion than its competence.

Defendants also emphasize that neither Dr. Belanger nor Dr.

Wilson agreed with Dr. Sweasey’s diagnosis. While this appears

to be another invitation for this Court to reweigh the evidence

that was before the Commission, which we decline to do, we also

note that both Dr. Belanger and Dr. Wilson testified that it was

plausible that a lifting injury could aggravate a previously
 -28-
asymptomatic degenerative cervical spine condition. Moreover, as

the Commission indicated, Dr. Wilson agreed that cervical cord

compression can be related to Chiari malformation and that, in

this circumstance, causation questions are best viewed

retrospectively because of the subtle onset of cervical cord

compression symptoms, which can overlap with Chiari malformation

symptoms and similarly do not become apparent until over time.

Accordingly, we hold that the Commission did not err in

concluding that Dr. Sweasey’s causation opinion was legally

sufficient to establish that Plaintiff’s 31 October 2008 lifting

injury caused an exacerbation or aggravation of his underlying

and pre-existing cervical spine condition.

Timely Notice to Satisfy Statute of Limitations

Defendants next argue that the Commission erred in

concluding that Plaintiff timely filed a claim for workers’

compensation benefits for his Chiari malformation caused by

intracranial hypotension based on the Form 18 that Plaintiff

filed on or about 1 July 2010 seeking benefits for injuries to

his neck, back, and leg. Specifically, Defendants contend that

because Plaintiff’s Form 18 did not explicitly reference the

injury to his brain, he should be barred from recovery for his
 -29-
brain sag by our Workers’ Compensation Act’s statute of

limitations. We disagree

As Defendants point out, N.C. Gen. Stat. § 97-24

establishes a two-year statute of limitations for claims for

compensation arising from work-related injuries, and although

Plaintiff’s accident occurred on 31 October 2008, Plaintiff did

not file any claims for compensation that specifically

referenced his resulting brain injury until he filed a Form 33

on 5 March 2012. Nevertheless, as our Supreme Court has made

clear, our State’s Workers’ Compensation Act “requires liberal

construction to accomplish the legislative purpose of providing

compensation for injured employees, and that this overarching

purpose is not to be defeated by the overly rigorous technical,

narrow and strict interpretation of its provisions.” Gore v.

Myrtle/Mueller, 362 N.C. 27, 36, 653 S.E.2d 400, 406 (2007)

(citation and internal quotation marks omitted).

In the present case, Plaintiff suffers from a rare brain

condition that is notoriously difficult to properly diagnose

given its symptoms, and we believe it would defeat the purpose

of the Act to deny him benefits because he was unable to fully

diagnose his condition himself within the two-year statute of
 -30-
limitations period. Moreover, because Defendants do not

challenge the Commission’s finding of fact that

[C]hiari malformation, tonsillar descent,
and brain sag affect the region of the body
where the cervical spine joins the brain
causing neurological abnormalities
throughout the central nervous system;
therefore, the Full Commission finds that
the Form 18 filed on or about July 1, 2010
referencing Plaintiff’s back and neck
sufficiently stated a claim for his medical
condition related to [C]hiari malformation
and that his claim is not time barred[,]

we consider it conclusive on appeal. Thus, we agree with the

Commission’s conclusion of law that the reference in Plaintiff’s

Form 18 to his neck, back, and leg sufficiently identified the

body parts affected by his work-related injury. Therefore,

because Plaintiff filed his Form 18 prior to the expiration of

the two-year statute of limitations, we hold the Commission did

not err in concluding Plaintiff’s claim was not time barred.

Temporary Total Disability Benefits and Medical Compensation

Finally, Defendants argue that the Commission erred in its

conclusions of law that Plaintiff is entitled to temporary total

disability benefits and medical compensation based on Dr.

Sweasey’s causation opinion. However, in light of the analysis

above, we hold that the Commission did not err in concluding

that Plaintiff’s brain and cervical spine injuries were
 -31-
compensable and that Plaintiff met his burden of proof by

satisfying the first prong of the Russell test through “the

production of medical evidence that he is physically or

mentally, as a consequence of the work related injury, incapable

of work in any employment.” Russell v. Lowes Product

Distribution, 108 N.C. App. 762, 765, 425 S.E.2d 454, 457

(citation omitted). Accordingly, the opinion and award of the

Commission is

AFFIRMED.

Judges CALABRIA and ELMORE concur.