Deterior Lumbar Case

HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year she began to complain of back pain that

DOI: 09/12/2014. Patient is a 45-year-old male vacation relief route sales representative who sustained a work-related injury to his lumbar spine from bending and pulling a bread product. Per OMNI entry, he was initially diagnosed with disc herniation at L4 to L5 with radiculopathy. He is status post extraforaminal L4 to L5 discectomy on 04/09/2015. He has been off work for nearly 2 years.

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.

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.

DOI: 12/3/2012. The patient is a 49-year-old male route sales representative who sustained a work-related injury to his lumbar spine and shoulders while lifting a bread rack out of his truck. Patient is status post bilateral L4-5 laminotomy, complete facetectomy and foraminotomy on 01/14/15.

DOI: 11/24/2011. The patient is a 48-year-old female home health aide who sustained injury while turning a patient in bed to put a clean pad when the bed moved. Per OMNI, the patient is diagnosed with L4-5 disc herniation with annular tear and left knee radicular syndrome. She has undergone posterolateral and interbody fusion at L4-5 on 02/18/2013.

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

DOI: 06/23/2011. This is a case of 41-year-old male maintenance worker who sustained injury to the low back while taking off a sliding door of a patio. As per OMNI notes, patient is diagnosed with lumbar disc disorder with myelopathy. MRI of the lumbar spine dated 6/28/15 revealed recurrent left paramedian L4-5 disc herniation with caudal extrusion of a 10 mm fragment into the left L5 lateral recess. As per office notes dated 7/25/16, the patient is status post redo left L5-S1 discectomy performed on 4/20/16. It was also noted that the patient had a prior L5 laminotomy several years ago. He subsequently did well. However, he had recurrence of his pain. Pain is radiating into his left leg worse on the right leg. This was unresponsive to conservative

His symptoms included pain in his neck, mid back, upper back, lower back, and left knee pain. Plaintiff described his neck pain as a 3 on the pain scale, his back pain as a 5 and his knee pain as a 6 on the pain scale. Plaintiff was prescribed 3 sessions per week for 6 weeks of physical therapy.

DOI: 05/07/1980. The patient is a 73-year-old male foreman who sustained a work-related injury to his lumbosacral spine, left knee, and right heel when a pile of lumbar fell on him. Patient is diagnosed with lumbar post laminectomy syndrome, foot drop, and non-union fracture. He has a history of hypertension and diabetes. He is status post 3 back surgeries, laminectomy at L4 to S1 in 1973, bilateral decompression laminectomy and discectomy at L4 to S1 in 1981, and 2-level fusion with failed fusion in 1991.

DOI: 5/1/2009. Patient is a 58-year-old male truck driver who sustained a work-related injury while he was on top of a load to loosen strap, when he lost his balance and suddenly jerked. As per OMNI entry, he underwent L4-L5 lumbar fusion with hardware on 3/28/2011, screw removal on 4/7/2011 and removal of hardware at L4-5, with inspection of fusion mass and revision of posterior spinal fusion on 04/22/13.

DOI: 4/13/2011. Patient is a 52-year-old male consolidator who sustained a work-related injury on 4/13/2011 after wrapping pallets. The patient was subsequently diagnosed with discogenic low back pain, lumbar facet arthropathy, and depression. Per medical report dated 5/25/2016, patient presents for re-evaluation of his low back pain. Pain has been worse over the last few days. He is having a lot of aching in the right side on his low back. He gets radiation to the right anterior leg. He feels that the leg pain has gotten worse over time. Currently, he takes tramadol extended release for pain. He takes Lexapro for depression. The medications are helpful. He tolerates them well. Pain is rated as 10/10 without medication and 6-7/10 with medication.

Patient’s chief complaint is midline lower lumbar spine pain with right anterior thigh pain. Insidious onset of the pain 3-4 years ago and now it’s daily and constant. Patient describe the pain as worse in the morning and will improve with mild movement. The low back pain gets worse by flexing forward, standing long time, coughing, sneezing, trunk rotation, rolling over in bed and walking up stairs. This patient also has posterior gluteal, thigh, and leg pain that occurs once a month. About the right anterior thigh pain, patient says it’s daily while lying in bed and most occurs in the morning. The pain resolves with mild