Pain Syndrome Case Studies

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DOI: 01/23/2015. Patient is a 62-year-old male foreman who sustained injury when he slipped off truck's metal step, fell from 6 feet, landed on his tailbone, and hit his right head. MRI of the lumbar spine dated 03/03/15 showed L5 to S1 marked disc degeneration with circumferential 4 to 6mm disc bulge with mild central protrusion and facet arthropathy causing marked bilateral lateral recess/foraminal stenosis with suspected S1 nerve root compression. At L2 to L3 and L4 to L5 there is mild disc degeneration with circumferential 2mm disc bulges causing mild bilateral foraminal narrowing, greater at L4 to L5, where mild facet arthropathy is also present.
Based on the medical report dated 01/04/17, the patient is status post left lumbar facet …show more content…

Pain is noted with lumbar extension. Tenderness is noted in the right L4-5 and L5-S1 facet joints. Patient was diagnosed with lumbar spondylosis and chronic pain syndrome.
Plan is for right lumbar facet ablation. He last had this done in October 2015. The patient notes he had about 60% relief for 10 to 11 months following that procedure. Patient had over 85% relief of their usual and chronic low back pain for 2 days after the injection. The patient notes that their functional capacity had improved as well, as evidenced as completing activities of daily living more effectively after the procedure. The patient's use of pain medications was also decreased after the procedure. Pain has returned.
MD did focus on the left hand side. Plan is for one right L4-5 and L5-S 1 radiofrequency facet ablation. It was further noted that the IW has had the following: severe pain that has failed to respond to six months of conservative management (e.g., physical/chiropractic therapy, oral medication, activity modification); pain is not radicular, it is confined to the low back; clinical findings and imaging studies do not suggest another obvious cause of the pain; and most importantly, a diagnostic, lumbar medial branch block with local anesthetic under fluoroscopic guidance has resulted in at least an 85% reduction in pain for the duration of the specific local anesthetic

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