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
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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
MRI of the lumbar spine performed on 10/30/14 demonstrated mild anterolisthesis and prominent degenerative changes at L4-5, resulting in contact and possible impingement upon passing L5 nerve roots bilaterally. There is moderate bilateral facet arthropathy at this level. Mild central canal narrowing is seen at L4-5. Mild chronic compression deformity, superior endplate of T12 is seen.
Assessments are lumbosacral intervertebral disc disorder with radiculopathy, lumbar spondylosis without myelopathy or radiculopathy and myalgia.
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.
Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is
Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last
MRI of the lumbar spine dated 07/30/15 demonstrated interval post-surgical change with removal of the disc extrusion at L4-5. There is residual granulation tissue versus broad-based left paracentral disc protrusion with left lateral recess stenosis.
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.
An MRI of the lumbar spine dated 03/23/17 revealed broad-based central 4 mm subligamentous disc protrusion and annular tear at L4-L5. There was a 2.7 mm subligamentous disc protrusion centrally at L5-S1. Neither of these two levels demonstrated compressive discopathy, central canal stenosis or foraminal impingement. There was a mild straightening of the normal lumbar
On examination of the lumbar spine, there is tenderness and guarding of the paraspinal musculature. Range of motion is decreased secondary to pain.
As of this report, an MRI done on 03/14/16 showed multilevel lumbar spondylosis. No significant central canal stenosis was noted. There were few areas of neural foraminal stenosis secondary to disc bulging and mainly bilateral facet
DOI: 11/13/2014. Patient is a 32-year old male technician who sustained injury at the time he was breaking loose a pulser component, he felt a sharp pain to his right side, low back buttocks and right leg. The patient was subsequently diagnosed with lumbar degenerative disc disease, radiculopathy and, lumbar spinal stenosis. Per MRI of lumbar spine without contrast dated 12/23/14 revealed at L4-5 there is disc space height loss, disc bulging and facet degenerative change; at L5-S1 there is posterior disc bulging resulting in mild narrowing of the central canal, and; at T11 to T12 there is posterior disc bulging resulting in mild narrowing of the central canal. As per focused history and physical dated 3/17/15, patient is presented to the office
As per medical report dated 2/18/16, patient complains of constant low back pain in a L4-5 distribution. Patient has undergone physical therapy as well as medication management without amelioration of the pain and continues to be symptomatic. He had previous epidural steroid injection. He also had acupuncture
Based on the progress report date03/16/16, the patient has been managed conservatively with PT and has continued to experience discomfort. His pain has migrated from primarily thoracic to more localized lumbar pain.
MRI of the lumbar spine done on 08/20/09 revealed multilevel mild chronic degenerative changes of the lumbar spine, most notable at L5-S1, L4-5 and L3-4 on the basis of chronic degenerative changes.
MRI of the lumbar spine dated 07/08/10 revealed relatively mild degenerative spondylosis and no evidence