Low Back Pain Management Case Studies

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.

DOI: 10/14/2009. Patient is a 44-year-old female hospital medical records clerk who sustained a work-related injury after tripping over a garbage can and fell on her right knee.

An MRI of the lumbar spine dated 03/23/17 revealed broad-based central 4 mm subligamentous disc protrusion and annular tear at L4-L5. There was a 2.7 mm subligamentous disc protrusion centrally at L5-S1. Neither of these two levels demonstrated compressive discopathy, central canal stenosis or foraminal impingement. There was a mild straightening of the normal lumbar

As per medical report dated 3/10/2016, patient complains of low back pain rated at 7/10 with left lower

Based on the progress report dated 02/09/16, the patient presents for follow-up. He describes ongoing difficulty with pain in both shoulders, wrists, low back and the bilateral lower extremities from the knees to the calves. His symptoms include pain, spasms, numbness and tingling. He rates his pain level as a 9/10 in intensity, but it is reduced to a 7/10 with use of his medications. He reports that morphine is helping, but he is still taking 5-6 Norco a day. He is also taking a stool softener three times a day as well as Linzess. However, he continues to have significant constipation.

MRI of the lumbar spine dated 07/24/15 showed degenerated L4-L5 disc. There is a significant foraminal narrowing at L4-L5 on the left with effacement of the left L4 nerve root.

Based on the latest follow-up physiatric evaluation report dated 01/11/16, the patient complains of lower back pain which improves temporarily with PT but continues to radiate to his left leg with numbness, tingling and weakness. He attends PT three days per week and participates in a daily home exercise program.

Based on the progress report dated 03/28/16, the patient complains of pain to his lumbar

OI: 11/22/2009. Patient is a 46-year-old female certified nursing assistant who sustained a work-related injury to her low back while helping move/lift a patient. Per OMNI, the patient is diagnosed with status post lumbar laminectomy surgery on 07/26/10, lumbar degenerative disc disease, and lumbar radiculopathy. She was deemed to have reached permanent and stationary status by PQME Dr. Well last 12/01/11.

The ROM was restricted, 50% of normal. The paraspinal muscle strength and tone was normal. The SLR was negative bilaterally. The exam of the left lower extremity was normal. The exam of the right lower extremity was normal except mild decreased strength in the right hip flexors. A reported MRI Lumbar Imaging on 07/01/15 showed multilevel degenerative changes; Previous L4 to sacrum fusion, evidence of herniated disc or significant central stenosis or foraminal stenosis. A reported MRI L Spine on 11/05/15 revealed herniated disc L2-3 with inferior extrusion impinging on the right L3 nerve root. Assessment: The patient has continuing symptoms of pain in the right lower extremity radiating down along the anterior thigh. This is consistent with the herniated disc at the L2-3 level on the right. He had previous surgery at the L2-3 level 3 years ago for his work-related

DOI: 7/2/2010. The patient is a 57-year-old female claims examiner who sustained work-related injuries to her bilateral knees, low back, psyche, cervical, shoulder and left hip while packing contents of desk.

Based on the progress report dated 11/10/16, the patient complains of constant lumbar spine pain, rated as 2/10. Pain is described as sharp, stabbing and throbbing. Pain is aggravated by prolonged sitting, standing and walking, and relieved by rest.

DOI: 9/9/2008. The patient is a 50-year-old male security guard who sustained injury to his back, right wrist, and right shoulder when he tripped over a chair and landed on the floor.

The patient is a 62-year-old male with a long history of cervical and lumbar pain secondary to degenerative disk disease and spondylosis. He also is noted to have multiple other problems including a fairly severe left rotator cuff arthropathy which does require surgery on the left. It is important to note that this is important because the patient has been wheelchair bound since 2013 and now has difficulty with ambulation. He also has a history of prior cervical decompression in the remote past at C3-4. The patient complains of both cervical and lower extremity pain as well as radiating symptoms in the left upper extremity all the way down into the level of the hand. He denies

The latest progress report noted that the patient has neck and low back pain rated 7/10. The Physical exam revealed restricted ROM in the lumbar spine. TTP and