Lumbar Spine Case Studies

Based on the latest medical report dated 04/08/16, the patient presents for follow-up of his lower back pain. He is status post radiofrequency facet on the left that initially helped with left sided lower back to 60%. He stated that PT was stopped by insurance for the past 2 weeks. Since he started PT, he has been having increased spasm across his lower back with pain into the left lower extremity. IW feels that PT

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

On September 30, 2014, Plaintiff presented to Houston Medical Group for treatment. Her primary symptoms were neck pain and low back pain. She described her

The patient is a 54-year-old male who sustained an injury on 10/06/14. No mechanism of injury was provided.

On the statement of medical necessity per MG-2 form dated 07/13/16, patient has been experiencing severe lumbar spine pain/spasms since the injury. She complains of lumbar spine pain with cramps in the lower extremity going down to the feet, associated with tingling sensation. There is left greater than right L3-S1 pain and spasms, left greater than the right L3-4, L4-5 and L5-S1 facet joint pain, upon posterolateral extension at 45 degrees. There is bilateral sacroiliac joint tenderness. There is tenderness over the right lateral quadriceps muscle. Range of motion (ROM) is limited secondary to

The patient is a 36-year-old individual who sustained an injury on 01/30/17 due to lifting.

On the statement of medical necessity per MG-2 form dated 10/18/16, the patient wants to repeat left L5-S1 x 1 for longer lasting pain relief. History and physical examination was consistent with lumbar radiculopathy/radiculitis (radiating pain and concordant MRI findings). She has failed conservative treatment options including nonsteroidal anti-inflammatory drugs (NSAIDS),exercise, core strengthening and PT. Pain limits the patient’s function, as well as restricts Activities of Daily Living. It is reasonable to try a left L5-S1 ESI x 1 for pain relief. If there will be no benefit, an interlinear approach will be attempted.

OI: 09/15/2012. Patient is a 67-year-old female home attendant who sustained injury to the back while she was lifting/transferring a client. Per OMNI, she is diagnosed with back pain.

On examination of the lumbar spine, there is tenderness at L4-S1, with spasms noted. Straight leg raise (SLR) is positive on the left side. As of this report, a urine drug screen was consistent with prescribed medications.

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)

DOI: 9/12/2015. Patient is a 41-year old male service technician who sustained injury to his lower back when he fell 3 feet backwards off a ladder. Per OMNI, he was initially diagnosed with sprain to the lower back and right shoulder.

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.

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.