Orthopedic Case Studies

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

Per the IME report dated 09/02/16, the IW would need to be followed for one year to determine if operative intervention is indicated. If no surgery is done in 1 year, IW is basically committed to conservative treatment. He has not reached maximum medical improvement. He has had sufficient PT and can be on a home exercise program. He has a moderate partial disability of 50%.

The patient is a 64-year-old gentleman who tells me nine or 10 days ago he started having pain in his right shoulder which started in the morning. He states that prior to this he has been doing increased amount of work at his horse farm. He has had to not only bale hay, he has needed to lift 15 car batteries up onto a platform. He also tells me he caught a heavy "I beam" and felt a jerk of his shoulder several days prior to onset of pain. He states the day after the onset of the pain, he had such back pain, he had a difficult time sleeping. He was taking Advil every six hours, but this was not helping the pain. At that point, the pain was gone up not only in his right shoulder but going up his neck and down his arm. He tells me that he then switched to Aleve, two tablets twice a day and started using ice alternating with heat. He states the ice seems to work magic for him and one week after the pain started he woke in the morning and had no pain. He states that he still gets an occasional twinge, but it is almost completely resolved. He does worry because he works on a horse farm and does not want to have any sort of intervention if not needed. He does occasionally get aches and pains in his shoulders and at this point, this is the state he is in.

DOI: 11/15/2010. The patient is a 56-year-old male sales representative who sustained a work-related injury when he tripped on a pallet. As per OMNI, the patient is diagnosed with strain to right knee, right leg and right shoulder and is status post right shoulder diagnostic and operative arthroscopy on 8/10/12.

MRI of the cervical spine without gadolinium dated 04/09/2015 showed severe 5mm left lateral recess focal disc protrusion with moderate canal stenosis and flattening of the left ventral cord and mild to moderate left neuroforaminal stenosis at C4-5. At 3-4, there was a moderate 4mm foraminal

Based on the latest medical progress report dated 05/16/16 by Dr. Merola, the patient complains of severe pain in the neck radiating

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

As per 4/1/16, the patient was seen at the request of his primary treating physician, Dr. Kevin Pelton. It was also noted that the patient did sustain lumbar spine injury. The patient complaints of neck pain which radiates over his right shoulder and into both upper extremities. He rates his pain

DOI: 10/06/2014. Patient is a 54-year-old female machine operator who sustained a work-related injury when she was struck on the right wrist with a heavy plastic shade while she was attempting to avoid falling. Patient is diagnosed with right radiocarpal sprain, right De Quervain’s tenosynovitis and pain in the limb.

01/08/16 Progress Report noted that the patient sustained an initial injury in June 2014, due to a cumulative trauma. She sustained a new injury in January 2015 as well. She sustained an injury to her neck, right shoulder, right arm, and right knee. She had X-rays and MRI post injury. Her right knee swelled, but improved right after she received treatment for her right shoulder and right knee. She received PT and chiropractic treatment twice a week, medications and surgery to her right shoulder in May 2015. She has received no treatment for her neck or left shoulder. She has not received acupuncture. The patient presented today with complaints of occasional, mild to moderate, throbbing neck pain, stiffness and cramping. The physical exam of the cervical spine revealed positive tenderness to palpation of the cervical paravertebral muscles and bilateral trapezii. There is also a muscle spasm of the cervical paravertebral muscles. The cervical ROM is decreased and painful. Shoulder depression causes pain. The exam of the thoracic spine showed tenderness to palpation of the thoracic paravertebral muscles, right trapezius, T1-T2 spinous process, T2-T3 spinous process, right Rhomboid and right lateral

DOI: 1/31/2011. The patient is a 61-year-old female family service coordinator who sustained a work-related injury when she fell on the ground. As per OMNI, the patient is status post right shoulder surgery on 5/10/2013, left knee surgery on 11/12/2013 and anterior cervical decompression and fusion C5-7 on 7/11/2014.

Per the QME report dated 08/21/14 by Dr. Hurria, the patient has a calculated total whole person impairment grating of 33%. Diagnoses include arthritis of both hips, status post right total hip replacement, cervical/lumbar sprain, radiculopathy to both upper and lower extremities, right cubital tunnel syndrome and impingement of both shoulders. Future medical treatment includes decompression of both shoulder, transfer of the anterior ulnar nerve

Per IME report dated 11/17/11 by Dr. Robert Michaels, MMI has been reached. From an orthopedic standpoint, the patient requires no further physical therapy, orthopedic treatment, or diagnostic testing.

MRI of the cervical spine was obtained on 06/29/15 which revealed a disc bulge with indentation of the ventral margin of the sac at C4-5 and C7-T1. There is a disc bulge with indentation of the ventral margin of the thecal sac and bilateral foraminal encroachment at C5-6 and C6-7 levels, with severe right neural foraminal narrowing by the encroaching disc.

DOI: 1/25/2016. Patient is a 59-year-old female sales representative who sustained injury when she bent over and strained her neck. Per OMNI entry, he was initially diagnosed with neck strain. Patient has completed 20 PT sessions.