Om Case Studies

Assessments are lumbosacral intervertebral disc disorder with radiculopathy, lumbar spondylosis without myelopathy or radiculopathy and myalgia.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

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.

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

11/13/14 MRI of the lumbar spine showed 4mm left paracentral and foraminal disc protrusion at L4-5, which mildly impinges upon the thecal sac and the proximal left L5 nerve root. The disc protrusion also moderately narrows the left foramen and lateral recess. There was also a 2mm posterior central disc protrusion at L5-S1. A 2mm disc bulge at L2-3 was seen. There was a mild degenerative facet and ligament flava hypertrophy at L4-5 and

She reports tenderness to the posterior aspect of the cervical spine, trapezius region and scapular region with deep palpation.

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

On examination of the lumbar spine, there is mild paraspial lumbar muscle tenderness to deep palpation. There is a questionable facet joint tenderness to deep palpation.

MRI of the lumbar spine dated 12/11/15 reveals disc desiccation with associated loss of disc height at L5-S1; posterior annular tear at L5-S1; hemangioma at L5; and L5-S1 focal right paracentral disc herniation which abuts the thecal sac. Disc measurement is 3.3 mm.

On examination of the lumbar spine, there is moderate to severe muscle spasm and tenderness of the paraspinal muscles and spinous process at L4-5. There was painful active

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.

Based on the medical report dated 08/31/15, the patient complains of low back pain, associated with numbness and parethesias. She has been treated with PT and is scheduled for her first lumbar ESI. On examination of the lumbar spine, range of motion shows anterior flexion of 30 degrees and extension and bilateral lateral bending of 10 degrees, all with pain. Straight leg raisin test is positive bilaterally Assessments are displacement of cervical and lumbar intervertebral discs without myelopathy. Conservative treatment consisting of PT, anti-inflammatory medication, pilates and/or

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

DOI: 1/23/2016. Patient is a 39-year-old male field technician who sustained a work related injury to his lower back when he strained his muscle when reaching under customer's desk. He was diagnosed with lumbar strain and herniated nucleus pulposus right L4/5.

DOI: 3/8/2011. Patient is a 49-year-old male route sales representative who sustained cumulative trauma to his neck, psyche, back, abdomen and lower extremity. Per OMNI entry, IW is initially diagnosed with chronic cervical and lower back pain with radicular symptoms, and chronic knee pain. Per the AME supplemental report dated 10/11/13 by Dr. Abeliuk, future medical care includes cervical and lumbar ESI, nonsteroidal anti-inflammatory drugs (NSAIDS), non-narcotic analgesics and access to 24 PT visits in two years, for flare-ups.