Cervical Raadiculopathy: A Case Study

DOI: 02/27/2014. The patient is a 63-year-old male driver who sustained lower back injury while unloading foods and fell between the loading dock and rear trailer.

DOI: 12/19/2012. Patient is a 52-year-old female laborer who sustained injury to her neck, back, and right shoulder due to motor vehicle accident. Per OMNI, she underwent an emergency neck surgery with 5 screws at C5-7 and back fusion and rod placement at T8-10.

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

Overall, Dr. Scharf’s report is quite concise. He documented the applicant’s current complaint as neck pain, radiating pain to both arms, and occasional headaches, as

Based on the medical report dated 12/22/16, the patient was last seen on 10/13/16, and was recommended to have continued therapy. He has not had therapy secondary to insurance issues over the last month or so. He presents with ongoing right elbow pain status post cubital tunnel release and medial epicondylitis debridement, worsening with motion and activity, lifting, reaching, bending, upper extremity dressing, household

cervical discectomy and fusion performed on 04/14/15. The latest progress report noted that the patient has neck pain, upper back pain, and shooting pain down the arms. The exam revealed that the DTRs were mildly diminished in the left upper extremity. The strength and sensation were mildly diminished in the left upper extremity as well. Spurling sign was also weakly positive on the left. It is noted that the patient has tried and failed conservative treatment, including medications and PT. However, review of the records revealed that the postop PT was put on hold due to his increased pain. In addition, the MRI Report showed that the disc space was normal and there was no significant disc herniation at the requested level i.e. C7-T1. The spinal canal and neural foramen are patent. In addition, EMG Report revealed that there was no evidence of peripheral nerve entrapment or underlying peripheral neuropathy on nerve conduction studies. Considering the minimal/mild physical examination findings and normal imaging and EDS testing; the medical necessity of C7-T1 cervical ESI has not been established. Recommend

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

Based on the progress report dated 03/01/16 by Dr. Ahmed, the patient continues to complain of constant lower back pain radiating to her left leg which she describes as sharp with pins, and needles and intermittent numbness and weakness.

Examination of the bilateral shoulder reveals tenderness to palpation about the anterior shoulders bilaterally. There is also restricted range of motion secondary to pain and her supraspinatus weakness and Hawkins’ impingement tests are both positive. In addition, Neer’s impingement and drop-arm tests are also positive.

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

Based on the medical report dated 04/11/16 by Dr. Au, the patient complains of neck pain and presents for a cervical epidural steroid injection. Pain is rated as 5/10 and described as stiff, tight and achy. Pain is worse with turning his head. He continues to do PT for his neck pain and shoulders with benefit.

01/08/16 Progress Report noted that the patient sustained an initial injury in June 2014, due to a cumulative trauma. She sustained a new injury in January 2015 as well. She sustained an injury to her neck, right shoulder, right arm, and right knee. She had X-rays and MRI post injury. Her right knee swelled, but improved right after she received treatment for her right shoulder and right knee. She received PT and chiropractic treatment twice a week, medications and surgery to her right shoulder in May 2015. She has received no treatment for her neck or left shoulder. She has not received acupuncture. The patient presented today with complaints of occasional, mild to moderate, throbbing neck pain, stiffness and cramping. The physical exam of the cervical spine revealed positive tenderness to palpation of the cervical paravertebral muscles and bilateral trapezii. There is also a muscle spasm of the cervical paravertebral muscles. The cervical ROM is decreased and painful. Shoulder depression causes pain. The exam of the thoracic spine showed tenderness to palpation of the thoracic paravertebral muscles, right trapezius, T1-T2 spinous process, T2-T3 spinous process, right Rhomboid and right lateral

DOI: 3/13/2007. The patient is a 58-year-old female registered nurse who sustained work-related injuries to her neck, lumbar, thoracic, shoulders and arms from lifting and moving patients. As per OMNI, the patient is diagnosed with cervical spondylosis and is status post cervical fusion on 1/12/10. MRI of the cervical spine dated 05/28/13 revealed post-operative changes in the lower cervical spine and degenerative changes which are most severe at C7-T1.

According to the progress report on 10/15/15, the patient is still having neck and left-sided upper extremity complaints. She has some complaints on the right side, as well. The patient’s hip seems to be causing her mild complaints only. She has not been able to get back to work. On examination, the patient has negative Spurling’s and foraminal compression tests on her right side; she only had neck pain with that. Her foraminal compression test on the left side

IW was diagnosed with lumbago, lumbar foraminal stenosis, lumbar degenerative disc disease and right knee articular cartilage tear.