Paraspinal Morphine: A Case Study

MRI of the lumbar spine obtained on 05/19/15 revealed at L2-3, endplate osteophyte formation and disc bulge contribute to a mild degree of spinal canal stenosis and a mild degree of bilateral neural foraminal compromise. At L3-4, a disc bulge eccentric leftward and endplate osteophytes formation are responsible for a mild degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a moderate degree of left neural foraminal encroachment. At L4-5, there is a diffuse disc bulge and endplate osteophyte formation which effaces the ventral aspects of the thecal sac and are responsible for a moderate-to-severe degree of spinal canal stenosis, a mild degree of right neural foraminal encroachment, and a severe degree of left neural foraminal encroachment. At L5-S1, a shallow disc bulge and endplate osteophyte formation contribute to a mild degree of left neural foraminal encroachment, without compromise of the spinal

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.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

On examination of the cervical spine, there is tenderness and tight muscle band is noted on both the sides of the paravertebral muscles. There is pain with extension and palpation of right facets.

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

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

The patient stated that overall the symptoms have decreased. Antalgic gait has improved. The pain is decreased but it increases in the morning. The patient reported pain 3/10-scale level. Rom and Muscle strength remained the same. Swelling has decreased. Tenderness to palpation in the lateral and medial malleolus decreased. Muscle testing plantar flexion remains weak. Dorsiflexion remains weak. Review of Systems revealed joint swelling and loss of bladder/bowel control. Treatment plan included PT

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.

associated with MI (p. 719). The mechanism of action of the drug is opioids act by binding to opioid receptors located in the central nervous system (mu receptors) and opioid receptors present in the peripheral nervous system which mediates an analgesic response and alters the awareness of and response to painful stimuli. Therefore, the therapeutic response to the body will be the decrease in the level of pain. Ciccone (2016), pointed out that morphine can be absorbed orally, which is the preferred route of administration. If patient experiences vomiting or nausea, then it can be administered as a suppository. The drug can also be administered via IV and with intrathecal infusion which is both absorbed rapidly into the body, and subcutaneous administration consumed in 20 minutes. Morphine can ingest into the body via epidural injection which takes 6-30 minutes to absorb into the body and via intramuscular injection which will absorb in 30 minutes. Concurring to Ciccone (2013), morphine is widely distributed in the system, in pregnant women, it crosses the placenta and deposits through breast milk in small amounts. Metabolism is done primary by the liver and morphine is excreted in the urine. The half-life of the drug is 2-4 hours in adults

On examination of the lumbosacral spine, there is tenderness to palpation of the paraspinals and L3-4 facets and left sacroiliac joint. Pain is made worst with extension and lateral bend.

DOI: 5/22/1957. Patient is a 58-year old male forklift operator who sustained a work-related injury on 8/8/1988 to his mid/lower back and hip when he slipped on ice in a freezer.

Per PT notes dated 01/14/16, the patient has attended 18 visits. He perceives70-80% improvement in his overall condition.

01/25/16 Progress Report indicated that the patient has continued pain in the cervical spine, which radiates down to the right arm above the elbow. There is some aching at the cubital tunnel with no distal numbness in the forearm and hand. She takes OTC ibuprofen to reduce pain. She presented with a pain of 2/10-level. The ongoing neck pain is located diffusely. It is described as burning. ROS was positive for insomnia, anxiety and depression. The exam revealed cervical spine tenderness. There is decreased ROM on flexion, extension, rotation and left lateral bending. Right & Left Shoulder: there was tenderness to palpation at the subacromial space and pain with restricted ROM on abduction. Lumbar: there was tenderness to palpation over the facet joint. The ROM was decreased on flexion, extension and lateral bending. Treatment Plan: continue Ibuprofen; recommend MRI; and Electro diagnostic studies of the right upper extremity. Follow-up is on 04/18/16.