Case Study: Lumbar Region Pain

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

The patient has a history of discectomy to the left with temporary improvement of his lumbar pain and lower extremity symptoms. He has reherniation to the left correlating to the L4-L5. He has had transforaminal epidural steroid injections and facet injections with relief of his lumbar pain.

On the statement of medical necessity per MG-2 form dated 07/13/16, patient has been experiencing severe lumbar spine pain/spasms since the injury. She complains of lumbar spine pain with cramps in the lower extremity going down to the feet, associated with tingling sensation. There is left greater than right L3-S1 pain and spasms, left greater than the right L3-4, L4-5 and L5-S1 facet joint pain, upon posterolateral extension at 45 degrees. There is bilateral sacroiliac joint tenderness. There is tenderness over the right lateral quadriceps muscle. Range of motion (ROM) is limited secondary to

12/31/15 Progress Report described that the patient has cervical spine, right shoulder, and right wrist pain. She rates her cervical spine at 8/10-scale level and frequent; right shoulder pain at 8/10-scale level; and bilateral wrist pain at 6/10-scale level. The pain is frequent and improved since last visit. Rest and medications make the pain better. Weather

This is a 22-year-old male with a 6/11/2015 date of injury. He reported injuring his lower back, June 11, 2015 while carrying a desk up the stairs to the second story.

Treatment plan includes refill of medications, weight loss/diet, home exercise program (HEP) nonsteroidal anti-inflammatory medications (NSAIDS)/ice and follow-up in 1 month.

The ROM was restricted, 50% of normal. The paraspinal muscle strength and tone was normal. The SLR was negative bilaterally. The exam of the left lower extremity was normal. The exam of the right lower extremity was normal except mild decreased strength in the right hip flexors. A reported MRI Lumbar Imaging on 07/01/15 showed multilevel degenerative changes; Previous L4 to sacrum fusion, evidence of herniated disc or significant central stenosis or foraminal stenosis. A reported MRI L Spine on 11/05/15 revealed herniated disc L2-3 with inferior extrusion impinging on the right L3 nerve root. Assessment: The patient has continuing symptoms of pain in the right lower extremity radiating down along the anterior thigh. This is consistent with the herniated disc at the L2-3 level on the right. He had previous surgery at the L2-3 level 3 years ago for his work-related

12/2/15 orthopedic report identified neck and upper back pain that radiates to the arms, worse on the right. There is loss of grip strength and weakness in both hands and arms, primarily the right. There is a burning sensation in the arms. Exam revealed atrophy in the intrinsic muscles of both hands. There is no hyperreflexia. The patient has poor gait and wears a neck brace. He has difficulty toe walking and heel walking. The physician recommended pain management at this time. The physical exam revealed limited ROM at the cervicothoracic junction. Current medications were not documented. Treatment plan included Vista collar, medications, and revision surgery: cervical osteotomy in order to realign his spine with augmented fusion more likely to the base of the skull.

Based on the medical report dated 12/13/16, the patient presents for follow-up. Lumbar discomfort is described as sharp, aching, burning, shooting, severe and continuous, comes and goes, discomfort, pain, random, varying with activity, increasing with movement, tightness, and throbbing. It is rated as 9/10 without medications and 6/10 with medications. The symptoms are aggravated by changing positions, lifting, pulling, pushing, carrying, sitting, twisting,

Based on the latest medical report dated 12/21/15, the patient complains of persistent severe pain in the lower back radiating to the buttocks and legs, greater on the left side.

As per 4/1/16, the patient was seen at the request of his primary treating physician, Dr. Kevin Pelton. It was also noted that the patient did sustain lumbar spine injury. The patient complaints of neck pain which radiates over his right shoulder and into both upper extremities. He rates his pain

As per office notes dated 8/26/16 the patient complains of dull and aching pain of the neck. She rates it as 7 without the medications and at 5/10 with medications. Pain is aggravate with activities and relieved with rest and medications. Neck pain us associated with headaches and radiating pain, tingling, and numbness to bilateral upper extremities. Patient is complaining of having acid reflex ad acute exacerbation of muscle spasm. Lumbar back pain is dull and aching rated at 6 without medications and 4 with medications. Pain is aggravated with activates such as forward back bending, lifting, prolonged sitting, standing, walking, and it is relieved with rest and medications. Lower back pain is associated with radiating pain, tingling, and

MRI of lumbar spine dated 5/3/10 (no official report) revealed mild lower lumbar spondylosis; moderate bilateral facet arthropathy at L5-S1 mildly narrows the bilateral neural foramina at this level; and mild congenital spinal canal stenosis from L2-L3 to L4-L5.