Facet Arthropathy Case Study

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• DOI: 2/8/2016. Patient is a 54-year old male laborer who sustained a work related injury/ fractured 3 ribs & back when he got stuck and fell on his left side against the concrete when he was operating jack hammer. The patient is subsequently diagnosed with Herniation of lumbar disc. As per workers’ compensation follow up dated 7/25/16, patient complains of low back and radiating pain. In the evaluation there was an S1 distribution with weakness that was quite significant. Of note, the test of the MRI scan revealed that L5/S1 had a broad-based disc bulge of 3.5 mm, bilateral facet arthropathy, and at L4/5 there is also a broad-based concentric bulge. Physical examination revealed that he is still having pain in the back going down into the buttock. It is not an acute radicular event.…show more content…
He has pain in the back, primarily in the buttock and the hamstring, and there is still weakness on the foot in plantar flexion. He still has good strength on dorsiflexion and plantar flexion but there is still a clear weakness on the left side and he still has a significant pain. He does have a diabetic neuropathy which is probably what is making it difficult to heal at a faster rate. Assessment and plan notes that it was quoted from the radiologist that there is an annular tear, a broad-based bulge at L5/S1 and 2-mm broad-based bulge at L4/5, mild bilateral facet arthropathy and what the radiologist calls is mild bilateral neural foraminal narrowing, but what the radiologist says is there is no acute extrusion at either 2 levels. Diffuse disc degeneration, lateral recess stenosis and foraminal stenosis is prominent at L4/5 and at L5/S1 based on this report. It was noted that the provider recommends cortisone shot at L5 with a smaller amount of cortisone shot at L4. It was also bnoted that since there is stenosis at that level that can result in the
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