Fusion Case Studies

DOI: 5/5/2015. Patient is a 53-year-old male engineer who sustained injury while lifting a 10 inches long steel bracket when he felt a pull in his lower back.

A subsequent visit with Dr. Carico, dated 05/12/2017, indicated that the claimant reported constant pain in the bilateral scalp area, dizziness when stooping down, and aggravated upper thoracic pain when lifting with hands. TENS unit and home exercises were recommended.

Pain is rated at 3-4/10. The patient saw Dr. Abbassi on 05/07/15 who recommended diagnostic medial branch blocks around L4-L5 and L5-S1 on the right side, 2 levels. The patient would like the medial branch blocks to be done. Dr. Abbassi further writes, “I believe he is a candidate for diagnostic medial branch blocks, 2 levels, at the time starting from L4-L5 and L5-S1 on the right, later L2- L3 and L3-L4 if he still has pain, and if these injections help him for a short while but significantly and then the pain returns then radiofrequency ablation is an option.” Diagnoses are chronic fracture of T8, upper thoracic pain, lumbar pain with radiation to left L5 region with left L5 radicular pain with moderate listhesis at L4-5 and mild to moderate bilateral L5-S1 denervation. Treatment plan includes diagnostic medial branch blocks, 2 levels, right sided, at L4-L5 and L5-S1, to await approval for physical therapy, modified duty, and follow-up in 4 weeks.

CA MTUS supports facet injections for non-radicular facet mediated pain. In addition, ODG criteria for facet injections include documentation of low-back pain that is non-radicular, failure of conservative treatment (including home exercise, PT, and NSAIDs) prior to the procedure for at least 4-6 weeks, no more than 2 joint levels to be injected in one session, and evidence of a formal plan of additional evidence-based activity and exercise in addition to facet joint therapy. This is an appeal to a previously denied request on 02/09/16. The latest note and the appeal letter stated that the reviewing doctor denied the joint injections because there was no documentation of ruling out radiculopathy. The bottom line is that this patient has MRI scan evidence of both disc pathology and facet arthropathy. It was noted that the patient has been symptomatic since 2005. He has continued back pain with a recent 10/12/15 date of

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

On examination of the cervical spine, there is tenderness and tight muscle band is noted on both the sides of the paravertebral muscles. There is pain with extension and palpation of right facets.

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

02/09/16 Progress Report noted that the patient has neck pain, upper back pain, and shooting pain down the arms. The pain is on the left side. It is rated as 3-4/10. It is stabbing, burning, and pins and needles. Medications and rest alleviate the pain. Work, standing, walking, and activity aggravate it. The patient has tried muscle relaxants, strong pain meds, PT, hot packs, and ice, all of which have helped, but he continues to experience substantial pain. The exam revealed that the DTRs were mildly diminished in the left upper extremity.

DOI: 09/18/2012. Patient is a 59-year-old male truck driver who sustained injury to his head, left eye, ribs, lungs, shoulder, and back when he lost balance and fell while he was removing tarp at an ecology sample area. Per OMNI entry, he was initially diagnosed with punctured lung and 2 fracture of the lumbar discs. Patient is status pots L4-5 discectomy on 02/27/16 and L4-5 posterior pedicle screw fixation on 06/26/13. Per Ortho AME Dr. Ovadia, IW‘s shoulder is not P & S. Neuro AME Dr. Wang opined that the IW has 10% whole person impairment rating on 09/22/16.

12/16/15 Progress Report indicated that the patient wakes up with headaches. She mentioned headache in the frontal vertex or temporal occipital areas. She also feels imbalance. She denies bruxism and has no significant neck symptoms. She reported having some minor neck tightness. She was being treated with acupuncture 2 X per week and craniosacral therapy 2 X per week. She noted that she was able to read better in the past two weeks. She had difficulty scanning a written page in the past. She also mentioned that her insomnia has slightly improved since initiating these 2 therapies. Physical exam showed no palpable spasms in her cervical region over her muscles of mastication. Cervical range of motion: backward flexion 70 degrees and forward flexion 60 degrees. She was able to turn 60 degrees to each side. She is able to tilt 40 degrees to other side. Comments: Based on the absence of objective findings, she has reached a medical end result with no need for any further treatment. No additional treatment or diagnostic testing is

Per medical report dated 10/26/15 by Dr. Parsioon, the patient was initially seen on 9/14/15 for evaluation and treatment of cervical pain. At that time, he had neck pain without radiculopathy and bilateral hand tingling. IW stated that physical therapy made his neck pain increase and he wanted to make sure that it is okay to continue this. His chief complaint is pain in his neck radiating to the right shoulder and arm. He states the only time he gets the tingling sensation in the hand is

IW was diagnosed with cervical strain with right arm dysesthesia with what appears lo he chronic regional pain syndrome of her right arm, right shoulder biceps tendonitis and subacromial bursitis with associated impingement, status post subacromial injection x 1, mild medial and lateral epicondylitis of her right elbow, carpal tunnel syndrome by EMG/nerve conduction velocity and reactive depression.

A visit note from Isabel Valdez, PA-C, dated 08/17/2017, indicated that the claimant presented with neck pain for 7 days and was seen in the ER. He continued to have a sharp pain in the left neck with a movement that worsens as the day progresses. His BMI was 42.6. He was diagnosed with spinal stenosis in the neck region. MRI of the cervical spine with and without contrast and

Based on the latest medical progress report dated 05/16/16 by Dr. Merola, the patient complains of severe pain in the neck radiating

The patient has positive facet loading bilaterally. He has no clonus. Gait is antalgic, with a straight cane.