Leg Raadiculopathy: A Case Study

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

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 AME report dated 05/11/15 by Dr. Pang, it was opined that the IW has reached MMI. Whole person impairment is 12 % for the thoracic spine and 17% to the lumbar spine. MD recommends provisions for the IW to seek medical attention for flare-ups or exacerbations with the possibility of undergoing PT, medications, further diagnostic imaging and

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.

Based on the latest medical report dated 04/08/16, the patient presents for follow-up of his lower back pain. He is status post radiofrequency facet on the left that initially helped with left sided lower back to 60%. He stated that PT was stopped by insurance for the past 2 weeks. Since he started PT, he has been having increased spasm across his lower back with pain into the left lower extremity. IW feels that PT

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

MRI demonstrates severe narrowing of the right fouramen due to severe collapse at L5-S1. EMG demonstrates positive radiculopaty. The claimant has severe back and right leg pain. The claimant has a positive EMG. The claimant has an MRI which demonstrates up and down stenosis in the foramen at L5-S1, compressing the L5 nerve root due to severe collapse of the L5-S1 disk. The claimant has elected to proceed forward with an anterior interbody fusion at L5-S1 with an anterior decomprssion and stabilization. The claimant has severe collapse of the L5-S1 disk resulting in foraminal stenosis. The provider states a posterior decompression alone would be inadeqate given the severe collapse of the disk and the up and down

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.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

There is collapse of the medial arch with calcaneal valgus with weight bearing. The IW functions in end range pronation throughout midstance of gait. There is tenderness upon palpation to the posterior plantar aspect of the left heel at the insertion of the calcaneus. There is mild pain with deep palpation to the right foot in the same location. She has pain with dorsiflexion and plantar flexion of the dorsal aspect of the left 1st metatarsophalangeal joint. There is no pain with active dorsiflexion and plantar flexion with resistance.

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.

The x-rays of Plaintiff’s spine showed normal alignment, no swelling, no fracture or dislocation and normal lordosis of the cervical and lumbar spine. Plaintiff’s left knee x-ray also showed no fracture or dislocation, but moderate decrease in the meduial articular joint space. Plaintiff was given a general diagnosis of neck pain, back pain, low back pain and left knee pain. Plaintiff was prescribed 3 sessions per week for 6 weeks of physical therapy.

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

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: 5/12/2015. Patient is a 57-year-old male crane operator who sustained injury when he felt pain in his lower back from moving multiple outrigger pads weighing approximately 80 pounds each. Per OMNI, he was diagnosed with lumbar strain. He is status post lumbar laminotomy at L3-L4 and L4-L5 on 03/01/2016