DOI: 02/27/2014. The patient is a 63-year-old male driver who sustained lower back injury while unloading foods and fell between the loading dock and rear trailer. 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
Per the PT daily note dated 05/27/15, the patient has attended 13 visits. 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.
Schopler was last evaluated on 8/03/2015. The consultant recommended epidural injection at right L4-L5. On examination of the back, there is slight to moderate pain to palpation of the right paraspinous muscles of the low back. Palpation reveals equivocal muscular spasm. The bilateral patellar and ankle reflexes are 0+.
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.
On examination of the lumbar spine, there is tenderness and guarding of the paraspinal musculature. Range of motion is decreased secondary to pain.
Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.
On examination of the lumbar spine, there is tenderness noted. Bilateral facet loading test is positive. Straight leg raise is positive bilaterally.
On examination of the lumbar spine, there is marked range of motion limitations in all planes with tenderness and spasm over paraspinal muscles. There is minimal improvement of symptoms.
Since the last visit dated 5/3/16, he states that he has been doing well. He notes that the physical therapy has been going well. He notices his pain and range of motion is improving. The patient notes that at least 30% improvement with physical therapy and at least 40% improvement with Vicodin. He also notes that at least 30% improvement while on his medication. He notes that he is able to get up out of bed, keep up with his hygiene, shop, and cook. He notes overall good improvement. The pain scale is 7/10 since his last visit on 5/3/16. Cervical spine examination revealed that range of motion is restricted with lateral rotation to the left limited to degrees due to pain and lateral rotation to the right limited to degrees due to pain but with normal flexion, extension, right lateral bending and left lateral bending. On lumbar spine, there is tenderness on the bilateral paravertebral muscles. Spurling’s maneuver causes pain. Lumbar facet loading is positive on both sides. Tenderness is also noted over the sacroiliac spine. Current medications include Ambien 10 mg, ibuprofen, and Vicodin
MRI of the lumbar spine was obtained on 05/22/14 which revealed status post posterior surgical fusion of L4, L5 and S1 with no evidence of recurrent/residual disc herniation. There is a mild disc bulge at T11-12, L2-3 and L3-4 levels.
CT of the lumbar spine without contrast dated 11/3/15 revealed post-surgical changes at L4-5 and L5-S1. Overall, there is very limited examination due to patient’s body habitus, with multilevel spondylosis. Findings are most notable at L4-5 where there is bilateral neural foraminal stenosis. There is atherosclerotic disease. There are few
MRI of the lumbar spine dated 08/31/16 showed a large broad-based herniation at the L4-5 disc level which is predominantly right-sided, although extends to the left lateral canal as well. There is central canal stenosis. There is a left-sided herniation laterally at the canal and at the proximal left foramen at the L5-S1 level. There is likely a transitional segment. If surgery is considered, anteroposterior views of the thoracic and lumbar spine are recommended. Changes suggesting prominent spasm are noted.
Muscle strength of the bilateral flexors shows 4/5. Patient is diagnosed with low back pain. It was noted that patient is not responding to Physical Therapy intervention for low back pain. IW is mechanically unresponsive to treatment for possible disc derangement. There is no lasting improvement with “STM” or use of lumbar traction.
ODG criteria for RFA include repeat neurotomies not to occur at an interval of less than 6 months from the first procedure. A neurotomy should not be repeated unless duration of relief from the first procedure is documented for at least 12 weeks at ≥ 50% relief. No more than
Based on the progress report dated 09/13/16, the patient reports unchanged intermittent moderate left foot pain. Patient also notes of intermittent moderate low back pain and left hand pain, that bothers her most. The patient went to a foot specialist last week, who administered an injection that increased pain and seems to have not taken effect yet.