Lumbar Pain Case Studies

In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend

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.

She reports tenderness to the posterior aspect of the cervical spine, trapezius region and scapular region with deep palpation.

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.

He reports no major changes in his condition, since his last visit. His pain is rated as 3-6/10, described as dull, hard, aching or worse. Pain is increased with sitting, standing, walking, lifting, looking up and down, turning to the sides, bending, and twisting. He is unable to work. He is very limited physically. He has to modify or avoid social and recreational activities to manage the pain. He feels like his quality of life is severely affected. His pain is 80% in the neck and 20% in the upper extremities, mostly on the

Based on the latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

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.

Review of diagnostic studies and medical-legal reports is included in the physician’s notes. Objective findings note that the patient is mildly obese and appears to be in moderate pain. He does not show signs of intoxication or withdrawal. His gait is antalgic gait and is assisted by cane. Lumbar range of motion is restricted with 50 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral bending, and 10 degrees of left lateral bending. All range of motion is limited by pain. There is tenderness noted in the bilateral paravertebral muscles. Lumbar facet loading is positive on the left side. Ankle jerk is ¼ on the right and 2/4 on the left. Patellar jerk is ¼ on the right side and 2/4 on the left side. There is tenderness noted over the trochanter and pain to the lateral hip with range of motion. Right side motor strength of ankle dorsi flexor is 4/5 and ankle plantar flexor is 4/5. Hip flexor is 5-/5. Light touch sensation is decreased over the lateral calf on the left. Patient has resting tremor of the left lower extremity. His medications are Prilosec 20mg, Celebrex 200mg, Neurontin 800mg, Flexeril 10mg, Duragesic 75mcg/hour patch, Viagra 100mg, Nuvigil 150mg, and Silenor 6mg, Evzio 0.4 mg, and Norco

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

On 12/19/2017, the claimant presented with lumbar pain. She had continued constant nagging pain with radicular pain in the left lower extremity. She had weakness and numbness. In 2012, she underwent L4-S1 fusion. She had lumbar medial branch block in 04/2017, which helped with the axial low back pain by more than 50%, but the radicular pain becomes severe. She stated that the previous bilateral L5 and left S1 selective nerve root block on 06/21/2017 provided 100% pain relief for 3 days before the pain gradually returned. She also had epidural steroid injection and trigger point injection, which did not help with the pain. The alleviating factors include medication, rest, heat, and TENS unit. The previous physical therapy and chiropractic care had helped significantly. Objective findings showed positive straight leg raise test on the left with tenderness in the left lower lumbar area and bilateral

Examination by Melissa Kliem, DPT, revealed flexion and extension increased pain in the cervical/lumbar region as well as in his upper extremities. Ms. Kliem noted bilateral hip range of motion was guarded due to increased central thoracolumbar region pain. He also exhibited increased chest pain with

He returned to see Dr. Kahmann and underwent further diagnostic studies. Approximately eight months ago, he underwent a two-level decompression. However, about three months after that, he was taken back to surgery for redo decompression at L2-3. Currently, there is constant burning pain in his left lower extremity along with hyposthesia and weakness. He finds it difficult to sleep at night because of his pain. Lumbar spine examination revealed well-healed anterior and posterior surgical scars. Lower extremity neurological examination revealed decreased sensation in the L2, L3, L4, L5 and S1 dermatomes. There was 4+/5 to 5-/5 strength in the left peroneals and left EHL, and an absent left AJ reflex. The SLR is positive on the left. Lasegue maneuver and femoral stretch are negative. Gait is waddling. Unable to heel walk on the left. Able to toe walk with some difficulty on the left. Lumbar ROM was significantly reduced. The patient is currently

12/2/15 orthopedic report identified neck and upper back pain that radiates to the arms, worse on the right. There is loss of grip strength and weakness in both hands and arms, primarily the right. There is a burning sensation in the arms. Exam revealed atrophy in the intrinsic muscles of both hands. There is no hyperreflexia. The patient has poor gait and wears a neck brace. He has difficulty toe walking and heel walking. The physician recommended pain management at this time. The physical exam revealed limited ROM at the cervicothoracic junction. Current medications were not documented. Treatment plan included Vista collar, medications, and revision surgery: cervical osteotomy in order to realign his spine with augmented fusion more likely to the base of the skull.

Pain/tenderness is noted at the thoraco-lumbar, lower thoracic/lumbar, upper/lower lumbar, lumbo-sacral and sacral. Moderate muscle spasms are demonstrated in the following areas: bilateral lumbar, bilateral sacroiliac, sacral, bilateral posterior pelvis/hip, and bilateral buttocks.

Based on the progress report dated 02/29/16, the patient is doing well but reports intermittent pain. He has had a lumbar ESI on 06/15 with no relief.