                                  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.
