Neck Pain Treatment Plan

Pain is rated at 3-4/10. The patient saw Dr. Abbassi on 05/07/15 who recommended diagnostic medial branch blocks around L4-L5 and L5-S1 on the right side, 2 levels. The patient would like the medial branch blocks to be done. Dr. Abbassi further writes, “I believe he is a candidate for diagnostic medial branch blocks, 2 levels, at the time starting from L4-L5 and L5-S1 on the right, later L2- L3 and L3-L4 if he still has pain, and if these injections help him for a short while but significantly and then the pain returns then radiofrequency ablation is an option.” Diagnoses are chronic fracture of T8, upper thoracic pain, lumbar pain with radiation to left L5 region with left L5 radicular pain with moderate listhesis at L4-5 and mild to moderate bilateral L5-S1 denervation. Treatment plan includes diagnostic medial branch blocks, 2 levels, right sided, at L4-L5 and L5-S1, to await approval for physical therapy, modified duty, and follow-up in 4 weeks.

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

Patient was encouraged to continue with heat, followed by his home exercise program and ice. He will continue with his transcutaneous electrical nerve unit (TENS). Patient was given an ice pack to use, to reduce pain. He was given a 60 mg Toradol injection on this visit.

Per the medical report dated 07/18/16, patient is being seen for her lower backache, rated 7/10 with medications and 10/10 without medications. Current medications include Ambien 10mg; Maxalt-MLT 10mg; Norco 10/325mg; Evzio 0.4mg; orphenadrine 100 mg and gabapentin 600 mg.

IW was diagnosed with sprain of the ligaments of the cervical spine. Patient has received chiropractic care. Response has been good and IW is encouraged with gains being made. Improved function and functional restoration are expected with additional treatments. Plan is for chiropractic treatment, 2 times a week for 3 weeks.

DOI: 4/01/2015. The patient is a 53-year-old-male old carpenter /foreman who sustained a work- related injury while lifting a high beam when the beam slipped before being placed into the ground pushing him between the beam and leads, crushing his right ankle and foot.

She did have an EMG nerve conduction study test of the upper extremity which did confirm evidence of chronic left C7 radiculopathy. She takes the hydrocodone 7.5/325 mg sparingly only when pain is intolerable. She also indicates she did experience significant improvement of her pain after she had a left C6-7 transforaminal epidural steroid injection in November 2015. She states she had relief for approximately 2 months. She states she is interested in trying another injection. Her pain is worse with activities using the left upper extremity, improves with rest and medication. She reports her pain level today is

Patient continues to manage pain with medications which brings the pain intensity from 7/10 on an average down to 3-4/10 and allows her to continue activities of daily living (ADLs) with less pain and stiffness. Patient states that without medications, she will not be able to function or move due to increase pain

12/01/15 Progress Report noted that the patient has cervical spine pain. Examination of the cervical spine revealed tenderness noted over the paraspinal and trapezius muscles. However, the exam revealed no discrete tender points or twitch responses on palpation over the neck. In addition, the latest report does not show any sensory or motor deficits. Furthermore, the PT reports available for review indicate that the therapy was done for bilateral hands and wrists. There is no documentation of the attempt of physical therapy of the cervical spine. There is no clear documentation of the failure of aggressive conservative treatment around the cervical spine. In addition, the request is for 15 injections and the guidelines do not support more than 3-4 injections per session. Therefore, the medical necessity of trigger point injections X 15 has not been substantiated. Recommend

Physical examination revealed that the patient’s back is less tender. There is facet tenderness over the bilateral L3-S1. There is also slight pain with limited rotation, flexion, and hyperextension. The right lower extremity is noted to be weaker. The lumbar spine examination is positive for seated straight-leg raise on the left and facet loading. As per treatment plan, the patient will be continuously evaluated for medication regimen and make alterations as necessary. It was noted that the patient states that there is continued need for his Zanaflex as necessary for flare-up of muscle spasms until he is able to start up chiropractor therapy again. He will try to discontinue the medication next month with chiropractor therapy. As per office notes dated 5/23/16, the patient’s pain level is 5-6/10. He states continued need for his Zanaflex as necessary for fare-up until he is able to start up chiropractic therapy. He continues to have neck pain with intermittent periods of sharp-stabbing pain over the right side with radiation to the bilateral upper extremities with numbness as well as associated cramping into upper extremity and into fingers. Current medications include Zanaflex, Nexium, Celebrex, and

Pain is rated as 2/10. Symptoms are located in the right posterior neck and right lateral neck. The pain radiates to the right shoulder and right arm. The patient describes the pain as aching and stinging. The patient describes symptoms as moderate in severity and worsening. Symptoms are exacerbated by use of the right arm, neck extension and neck movement. Associated symptoms include headache and upper extremity weakness. Current treatment includes non-opioid analgesics and opioid analgesics. The patient is currently able to do activities of daily living with limitations and able to work with

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.

Plan is to continue PT for the neck. Patient would benefit from PT to restore normal function and activities of daily living.

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