MTUS Case Paper

Was intact to primary modalities with no extinction on double simultaneous stimulation. He did have a subjectively decreased sensation on the right arm and leg compared to the left.

Once Dr. Swartz acknowledged the ROM method was improper in this case, I turned Dr. Swartz attention to the DRE method. After reviewing the table for the DRE Lumbar Category on page 384 of the AMA Guides, Dr. Swartz placed the applicant into a DRE Lumbar Category II and assigned an impairment of 5% WPI. Dr. Swartz supported her opinion based on the fact there is a subjective complaint of pain radiating into the applicant right leg as documented in his evaluation report of June 16, 2016. However, Dr. Swartz acknowledged there is no objective evidence to verify the radicular complaints, thus the placement into DRE Lumbar Category II is appropriate since there is no verifiable radicular complaint.

Met with PO for 30 minutes individule session. The session was focused on reviewing treatment progress and discuss continuing care plan.

It was noted that the patient has neck pain, facet arthropathy and spondylosis, suggestive of facer joint origin, 80% relief from previous facet nerve injection/block, prior rhizotomy more than 6 months and cervical/thoracic facet medial branch nerve block which has been helpful, failed conservative treatments with nonsteroidal anti-inflammatory medications (NSAIDS), PT, chiropractic care and home exercises.

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

The claimant underwent a medial nerve block for spondylosis-lumbar sacral on September 8, 2017 and September 15, 2017 (Ex. B21F).

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.

Based on the progress report dated 03/02/16 by Dr. Ozaeta, the patient has had a right knee corticosteroid injection one week ago. She had to take a Norco yesterday for right knee pain. She saw Dr. Cantrell, who requested 8 additional physical therapy sessions. She has low back discomfort, notable when sitting. She takes nortriptyline and an antihypertensive.

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

Area of Concern #1: In several case files, and across local offices, the federal review team noted instances of data entry that took place two months or longer after the actual activity.

On 10/2/17 I met Mr. McDoanld at the pain clinic in IINN. We met with Dr. Algahera. Mr. McDoanld reports and demonstrates shifting in positions due to pain. He reports he has right leg radiation at times. He continues to have trouble with sleeping and getting comfortable. Mr. McDoanld doesn’t want to take a narcotic pain medication. He is taking Flexeril at bedtime along with Motrin. Lidoderm will now be added to see if that helps with sleep. Mr. McDoanld also has a TENS Unit to use as needed. Dr. Algahera said Mr. McDoanld has 2 things going on. The compression of the disc and also a pinched nerve. He would recommend doing the Kyphoplasty first then moving on to epidural injections. Mr. McDoanld is being set up for an appointment

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.

An Epidural Steroid Injection is a block that is most commonly used to reduce pain and inflammation as well as helpful in pain relief by delivering the anti-inflammatory medication directly to the source of the problem. Epidural Steroid Injections are used to reduce the inflammation associated with lumber disc herniation,spinal stenosis or degenerative disc disease, enabling the patient to pursue physical therapy/rehabilitation. While patients found a reduction in pain by taking an epidural steroid injection, there would be better response

Isler completed her examination and reviewed the MRI and EMG. Dr. Isler informed Mr. Emm that she still recommends the injections and felt it was still his SI and arthritis. The physician continued physical therapy and the same work restrictions from the prior appointment. I inquired on massage therapy and Dr. Isler replied she did have this down for treatment. Dr. Isler clarified with Mr. Emm on if they were using a TENS unit and Mr. Emm replied they had and it seems to help a little. Dr. Isler recommended one for home use. I inquired about using tennis balls or medicine ball to desensitize the area. Dr. Isler that this was a good idea and recommended that therapist instruct Mr. Emm on the usage. Dr. Isler provided Mobic 15 mg by mouth one a day for the next 30 days. Mr. Emm replied he had Flexeril at home and had not been using it as he felt it played with is mind. A return appointment was scheduled for November 3, 2017 at 11:00 a

For decades the gold standard in pain management treatment has been steroid injections for spinal or extremity pain issues. These cortisone injections work well with excellent results over 75% of the time. However, steroid injections do not alter the course of arthritis or soft tissue injury. They simply offer pain relief for a finite time period and then need to be repeated usually. In addition, there are significant limitations on the frequency with which corticosteroid injections may be performed due to potential adrenal gland problems