Lumbar Spine: A Case Study

MRI of the lumbar spine performed on 10/30/14 demonstrated mild anterolisthesis and prominent degenerative changes at L4-5, resulting in contact and possible impingement upon passing L5 nerve roots bilaterally. There is moderate bilateral facet arthropathy at this level. Mild central canal narrowing is seen at L4-5. Mild chronic compression deformity, superior endplate of T12 is seen.

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

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

As per medical report dated 4/19/16, a lumbar MRI with and without contrast was requested to evaluate for a discogenic and/or facetogenic etiology for pain. MRI would also allow evaluation of conditions such as spinal stenosis.

DOI: 11/24/2011. The patient is a 48-year-old female home health aide who sustained injury while turning a patient in bed to put a clean pad when the bed moved. Per OMNI, the patient is diagnosed with L4-5 disc herniation with annular tear and left knee radicular syndrome. She has undergone posterolateral and interbody fusion at L4-5 on 02/18/2013.

DOI: 4/01/2015. The patient is a 53-year-old-male old carpenter /foreman who sustained a work- related injury while lifting a high beam when the beam slipped before being placed into the ground pushing him between the beam and leads, crushing his right ankle and foot.

DOI: 9/30/1997. The patient is a 50-year-old female reservation clerk who sustained a work-related injury to her back and bilateral lower extremities when she tripped and fell.

Stand and gait is normal, pain in dermatome L5 and S1 both side , local pain in the lower lumbar area , sensation intact ,no muscle weakness , reflex status normal .

MRI scan of the lumbar spine with contrast dated 7/17/2015 showed compression of the descending left L5 nerve root at L5-S1 on the basis of a 6.1mm left paracentral disc extrusion and compression of the descending left L4 nerve root at L3-L4 on the basis of a 6mm left-sided pre-foraminal and foraminal disc extrusion.

As of this report, an MRI done on 03/14/16 showed multilevel lumbar spondylosis. No significant central canal stenosis was noted. There were few areas of neural foraminal stenosis secondary to disc bulging and mainly bilateral facet

02/09/16 Progress Report noted that the patient’s current medication regimen provides moderate pain relief without any adverse effects. The patient stated that he has seen Dr. Smith for IT pump clearance and would like to proceed with the trial. He has chronic lumbar back pain. The pain radiates the left buttock, left posterior thigh, left lateral thigh, left lower leg, left foot, and right lateral thigh. The patient describes the pain as sharp, dull, aching, bumping, stinging, and throbbing. The onset was sudden immediately after the injury. The symptoms are constant and the episodes occur daily. The symptoms are described as severe and worsening. Back motion, lifting, and bending exacerbate the symptoms. Associated symptoms include leg numbness, foot numbness, leg weakness, and foot weakness. Current treatment includes opioid

On examination of the lumbar spine, there is moderate to severe muscle spasm and tenderness of the paraspinal muscles and spinous process at L4-5. There was painful active

MRI of the lumbar spine dated 07/08/10 revealed relatively mild degenerative spondylosis and no evidence

Based on the progress report dated 08/25/16 by Dr. Ahmed, the patient complains of left shoulder pain, neck pain, low back pain, and right ankle pain. IW have received certification for 12 visits of physical therapy to the lumbar spine and right ankle. Overall, the pain and symptoms remain the same. Patient also complains of difficulty sleeping due to

12/07/15 Progress Report described a follow-up visit. The patient continued to report adequate pain with the use of Vicodin and Flexeril. Review of utilization review report indicated that these medications were no longer certified. However, TPI trial with anesthetic has been certified. The patient noted 5/10-scale level pain in the lumbar region without radiation. He denied any side effects of the medication. Examination revealed trigger points with a jump response on palpation of the lumbar paraspinal muscles. The ROM is restricted in the lumbar region secondary topain and stiffness. Faber sign is positive on the left. SI joints are non-tender. SLR and sitting SLR are negative. Treatment plan included Vicodin and Flexeril. Work status: Return to full duty; avoid lifting > 20 lbs and frequent bending activities.