Lumbar Spine: A Case Summary

IAT is reporting they received an adverse verdict in the amount of $2,305,376 on 10/13/16, with likelihood the plaintiff will be awarded additional monetary damages based on jurisdictional laws.

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.

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

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

On examination of the lumbar spine, there is tenderness and guarding of the paraspinal musculature. Range of motion is decreased secondary to pain.

01/06/16 Pain management Report described that the patient has a history of chronic low back pain and right lower extremity pain. The patient has a spinal cord stimulator since 01/30/15. The patient visited today for follow-up and medication refill. He reported that his pain has been stable since the last month. His pain is 5/10-scale level with the use of medications and 8/10-scale levels without the use of medication. The patient reported that the medications, activity restriction,

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

DOI: 4/26/2006. Patient is a 51-year-old male chief engineer who sustained a low back injury when he was using a snap pipe cutter and felt low back pain. Per OMNI, he underwent an L4-5 right redo hemilaminotomy and discectomy on 05/07/2007 and an L4-L5 posterior spinal fusion with instrumentation and an L4-L5 transverse lumbar interbody fusion with a cage on 8/29/2011.

As per medical report dated 2/18/16, patient complains of constant low back pain in a L4-5 distribution. Patient has undergone physical therapy as well as medication management without amelioration of the pain and continues to be symptomatic. He had previous epidural steroid injection. He also had acupuncture

DOI: 7/14/2015. Patient is a 32-year-old male carpenter who sustained a work-related injury when he slipped with tanks falling on him as he was moving cart with cutting torch and tanks uphill. As per Omni, the patient has herniation at L4-L5 level.

DOI: 12/09/2000. This is a 58-year-old male sanitary engineer who sustained an injury to the low back when he fell while stepping down a ladder. Patient is diagnosed with other intervertebral disc degeneration, lumbar region. He is status post lumbar spine surgery on 05/19/2006. Per medical report dated 5/26/16, the patient complains of lower back pain which has increased since his last visit, rated as 9/10 without medication. His quality of sleep is poor and activity level remains the same. As per office notes dated 6/26/16, the patient rates his pain as 9 with medications and 10 if without medication. He states that the medication is working well and no side effects noted. CURES (Controlled Substance Utilization Review and Evaluation System)

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.

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.

DOI: 4/13/2011. Patient is a 52-year-old male consolidator who sustained a work-related injury on 4/13/2011 after wrapping pallets. The patient was subsequently diagnosed with discogenic low back pain, lumbar facet arthropathy, and depression. Per medical report dated 5/25/2016, patient presents for re-evaluation of his low back pain. Pain has been worse over the last few days. He is having a lot of aching in the right side on his low back. He gets radiation to the right anterior leg. He feels that the leg pain has gotten worse over time. Currently, he takes tramadol extended release for pain. He takes Lexapro for depression. The medications are helpful. He tolerates them well. Pain is rated as 10/10 without medication and 6-7/10 with medication.

SOAP note dated 06/23/2017 stated that the claimant complained of cervical, thoracis and lumbar spine pain. The claimant also had swelling related to neuropathy. The claimant's blood pressure was 141/105. The physical examination revealed significant muscle spasm with moderately reduced and painful range of motion in the cervical spine, as well asn neck pain. There was positive cervical dystonia and positive facet loading as well. Examination of the back revealed significant muscle spasm and moderate pain with range of motion, positive bilateral hip and sacroiliac joint tenderness. There was decreased mobility, decreased lumbar spine extension and positive facet loading test. There was positive bilateral L5 radiculopathy. There was numbness in the lower extremities and non-pitting edema in the bilateral legs. The claimant was diagnosed with cervical spine pain, chronic lower back pain, chronic pain syndrome, lumbar spine radiculopathy and radiculitis nad cervical sponsylosis without myelopathy. The treatment plan included continuing with chiropractic care, physical therapy, LSO, and medication management.