Corpectomy Case Summary

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.

DOI: 7/7/2015. The patient is a 48-year-old male cleaner who sustained a work-related injury to his back while moving a heavy bookcase. As per OMNI, the patient was diagnosed with lumbar degeneration, thoracic or lumbosacral neuritis and myofascial pain.

Based on the medical report dated 04/01/16, the patient complains of pain in the neck with radiation to bilateral upper extremities and pain to the lower back with radiation to the lower extremities with tingling/numbness and weakness. He rates his pain 8-9/10.

In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend

IW was diagnosed with sprain of the ligaments of the cervical spine. Patient has received chiropractic care. Response has been good and IW is encouraged with gains being made. Improved function and functional restoration are expected with additional treatments. Plan is for chiropractic treatment, 2 times a week for 3 weeks.

The patient was compliant to all aspects of treatment and the home exercise program. There are no known alternate explanations of the outcomes of this case report. However, in comparison to the case report by Caldwell et al25., the patient in this case report displayed a faster decrease in pain and return to normal function indicated by 0/10 VAS, 0% neck disability and ability to perform all tasks for work at the last day of treatment, 3 weeks from the first day of physical therapy. Possible explanations for the faster recovery could be due to the slight difference of impairments as well as the addition to grade IV and V manipulations to the cervical and thoracic spine as suggested to have high correlation with decrease in pain and normalization

DOI: 7/2/2010. The patient is a 57-year old female claims examiner who sustained a work-related cumulative trauma injury to multiple body parts that include head/cervical spine, shoulders, arms knees, and left hip. As per progress report dated 7/11/16, the patient reports neck and low back pain. IT was noted that the pain is associated with left lower extremity numbness, tingling, and weakness. The patient has tried and failed multiple anti-inflammatories, which causes gastrointestinal upset, except for Celebrex. Her psychiatrist, Dr. Nehoryan has recommended her current regimen including Cymbalta and Restoril intermittently for sleep. It was mentioned that the patient had a fall in early 2/2016 due to left lower extremity numbness and is continuing

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 latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

She said she is trying to wean herself off from the prescription drugs which block the pain and will resort to possibly having acupuncture. She said with the use of home exercises and water therapy; she will start receiving acupuncture which is an out of pocket expense by receiving acupuncture through J Chu Hsiang MD Ph.D. at an address at 17777 Crenshaw Blvd., #102, Torrance CA 90505; 310-715-2858. She does not know when she will set-up an appointment with him.

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.

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

Based on the latest report dated 09/23/16, the patient complains of 7-8/10 neck pain, radiating to both shoulders. Patient continues to have numbness and tingling in both hands. She started to wear cock up splints at night for her bilateral carpal tunnel syndrome, which helps decrease her symptoms. Patient has moved back to NY and needs to complete 5 PT sessions from 10 symptomatic sessions per year. She has used 5 sessions in VA.

DOI: 1/16/2002. Patient is a 54-year-old male machine shop associate who sustained a work-related injury due to slip/fall while climbing down a ladder from the operator platform. He is in poor health due to uncontrolled diabetes. As per OMNI, he was diagnosed with lumbar spondylosis and cervical disc disease.