Lumbar Lordosis Case Summary

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.

Assessments are lumbosacral intervertebral disc disorder with radiculopathy, lumbar spondylosis without myelopathy or radiculopathy and myalgia.

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

MRI of the cervical spine dated 08/17/16 showed at C3-4 and C4-5, there is mild posterior disc bulging.

11/13/14 MRI of the lumbar spine showed 4mm left paracentral and foraminal disc protrusion at L4-5, which mildly impinges upon the thecal sac and the proximal left L5 nerve root. The disc protrusion also moderately narrows the left foramen and lateral recess. There was also a 2mm posterior central disc protrusion at L5-S1. A 2mm disc bulge at L2-3 was seen. There was a mild degenerative facet and ligament flava hypertrophy at L4-5 and

Post injection, he states he had 95% improvement temporarily for several days, but since then his pain to his lumbar spine has returned.

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

Goals of Treatment Plan include decreasing pain/spasms, increasing range of motion/ability to perform normal activities of daily living/strength, returning the patient to his pre-clinical status and increasing function. Long term goals include the reduced usage of over-the-counter/prescription medications as well as an increase in up to 5-10 repetitions of therapeutic exercise/neuromuscular education and an increase in 2-5 minutes of spinal endurance exercises (recumbent bike/ergometer) by the next

Per the QME report dated 06/11/16, patient has reached maximum medical improvement and is P & S. Future medical care includes physical therapy for neck pain flares four to six visits twice a year, follow-up with a physiatrist or occupational health physician intermittently, every one to three months and nonsteroidal anti-inflammatory drugs for flare-ups. He declines injections.

Treatment rendered to date included medications and physical therapy (PT). The pain was relieved by 50% due to medication use. Surgical history and diagnostics were not provided in the report.

The patient’s pain has clearly lasted beyond the anticipated time of healing. Previous methods of treating chronic pain have been unsuccessful and there is an absence of other significant options likely to result in significant clinical improvement. She has had conservative care including pain medication, braces/casts, physical therapy, transcutaneous electrical nerve stimulation unit (TENS), massage, exercise program, acupuncture, and chiropractic therapy. She is currently not a surgical

Based on the medical report dated 08/31/15, the patient complains of low back pain, associated with numbness and parethesias. She has been treated with PT and is scheduled for her first lumbar ESI. On examination of the lumbar spine, range of motion shows anterior flexion of 30 degrees and extension and bilateral lateral bending of 10 degrees, all with pain. Straight leg raisin test is positive bilaterally Assessments are displacement of cervical and lumbar intervertebral discs without myelopathy. Conservative treatment consisting of PT, anti-inflammatory medication, pilates and/or

Based on the latest medical report dated 12/21/15, the patient complains of persistent severe pain in the lower back radiating to the buttocks and legs, greater on the left side.

Since the last visit dated 5/3/16, he states that he has been doing well. He notes that the physical therapy has been going well. He notices his pain and range of motion is improving. The patient notes that at least 30% improvement with physical therapy and at least 40% improvement with Vicodin. He also notes that at least 30% improvement while on his medication. He notes that he is able to get up out of bed, keep up with his hygiene, shop, and cook. He notes overall good improvement. The pain scale is 7/10 since his last visit on 5/3/16. Cervical spine examination revealed that range of motion is restricted with lateral rotation to the left limited to degrees due to pain and lateral rotation to the right limited to degrees due to pain but with normal flexion, extension, right lateral bending and left lateral bending. On lumbar spine, there is tenderness on the bilateral paravertebral muscles. Spurling’s maneuver causes pain. Lumbar facet loading is positive on both sides. Tenderness is also noted over the sacroiliac spine. Current medications include Ambien 10 mg, ibuprofen, and Vicodin

History of Present Illness: JE is a 86-year-old Caucasian female that has low back pain. She states that her low back pain is a 10/10 at its worst, but that pain medication makes it feel better. The pain is not made worse or better through any of her day to day activities. The patient states that the pain started 20 years ago when she was trying to move her disabled husband out of bed. Ever since the pain comes and goes, but for the past few months the pain has been constant. The pain is not describable, JE says that it is the worst pain she has ever felt.