Myalgia Case Studies

Decent Essays
This is an appeal to a previously denied request for C6-C7 interlaminar ESI.

This is a 55-year-old female with a 3/25/2015 date of injury. A specific mechanism of injury has not been described.

Diagnosis: Myalgia
Cervical Radiculopathy

12/21/15 Progress Report noted that the patient has a history of pain in the neck and left arm. He is s/p C7-T1 interlaminar injection on 11/17/15. She reports some improvement post injection overall, but still some pain. Current medications: Gabapentin, Butalb/Acetaminophen/Caffeine (Fioricet). Tramadol, Hydrocodone/Acetaminophen (Norco 5/325 mg), Paroxetine (Paxil), Tizanidine, Alprazolam, Meloxicam, and Valsartan/Hydrochlorothiazide (Diovan). She has pain from the down the left arm to the elbow. She
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On examination the cervical ROM was restricted in all planes. Spurling’s test was positive on both sides, worse on the left. Sensations to light touch were decreased in the left hand 1-2 digits, which indicates sensory losses at C6-C7 levels. This level is most remarkable on the imaging as well. The MRI revealed 3mm protrusions at C6-7, with mild canal stenosis at this level; and mild to moderate foraminal stenosis greater on the left at C6-7. The patient has tried and failed conservative treatment including, PT, TPI, and medications. In addition, the patient reported functional improvement and pain relief from the first ESI, which was performed at a different, level i.e. C7-T1. CO Guidelines state indications for ESI :injections are allowed for only a small subset of patients with radicular findings. They may be used for patients who are having significant pain that is interfering with daily functions and the active therapy necessary for recovery despite medical pain management and active therapy. Injections should be preceded by an MRI. Interlaminar injections should not be done above level C6-C7. Guidelines have been met. Medical necessity of cervical ESI has been established. Recommend
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