Post Lumbar Discontinue: A Case Study

Once Dr. Swartz acknowledged the ROM method was improper in this case, I turned Dr. Swartz attention to the DRE method. After reviewing the table for the DRE Lumbar Category on page 384 of the AMA Guides, Dr. Swartz placed the applicant into a DRE Lumbar Category II and assigned an impairment of 5% WPI. Dr. Swartz supported her opinion based on the fact there is a subjective complaint of pain radiating into the applicant right leg as documented in his evaluation report of June 16, 2016. However, Dr. Swartz acknowledged there is no objective evidence to verify the radicular complaints, thus the placement into DRE Lumbar Category II is appropriate since there is no verifiable radicular complaint.

An attending physician statement completed by Dr. Peter Chweyah (Internal Medicine), dated 06/16/2016, indicated that the claimant presented with complaints of lower extremity weakness, neuropathy, weight loss, acute renal failure, and gout, as well as anemia. Objective findings showed an extreme weakness of the legs and pain in the feet. He also had diabetes mellitus type 2, chronic kidney disease, and hypertension. It was noted that the claimant was totally disabled from 05/30/2017 through 06/15/2017 and 05/23/2017 - 05/26/2017 secondary to gout.

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

DOI: 1/23/2014. This is a 36- year old male relief driver who sustained injury while he was putting away the automatic tarper when he was struck on the right shoulder and got driven into the ground and twisted his right foot. Per OMNI, he was diagnosed with right shoulder strain, and back/neck/right foot fracture. As per office notes dated 6/3/16, the patient is complaining of numbness in all extremities specifically the bilateral feet, arms and bilateral elbows. He has had a flare-up of pain that past couple of weeks around lateral column of the right foot made worse with walking and standing. He has been taking Neurontin 300 mg thrice a day which is helping control his symptoms. He apparently had a bilateral upper extremity upper extremity

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.

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

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

Patient unable to walk heel to toe, perform the Romberg test, stand on one foot, or perform a shallow knee bend without risk of falling. The patient complains of lower back, hip, and knee pain. . Assessed patient’s pain at this time. Patient states that, “the pain is felt in her lower back, hips, and knees constantly and relieved with ibuprofen” she rated the pain a 4 on a scale from 0 to 10. Patient stated, “lower back always aches.” Described the pain as constant and dull. Affects her activities of daily living because she “isn’t able to cook, clean, or exercise.” In a supine position the patient, with help, was able to extend legs upwards about 40 degree and flex hips with limited range of motion. Patient was able to resist with light resistance when pressure was applied to the legs anteriorly and posteriorly. Sitting back in the patient’s chair, the patient was able to bend at the hip. No pain or tenderness felt when palpating the spinous process. The patient was able to actively flex and extend the ankle joints with limited range of motion and some resistance with support under the lower leg. The patient was able to flex and extend the feet with limited range of motion and some resistance. No pain or crepitus with flexion and extension of the feet and ankles. Inspected the patient’s skin of the anterior and posterior legs, ankles, and feet. The skin of the upper legs were dry, with

DOI: 7/2/2010. The patient is a 57-year old female claims examiner who sustained a work-related cumulative trauma injury to multiple body parts that include head/cervical spine, shoulders, arms knees, and left hip. As per progress report dated 7/11/16, the patient reports neck and low back pain. IT was noted that the pain is associated with left lower extremity numbness, tingling, and weakness. The patient has tried and failed multiple anti-inflammatories, which causes gastrointestinal upset, except for Celebrex. Her psychiatrist, Dr. Nehoryan has recommended her current regimen including Cymbalta and Restoril intermittently for sleep. It was mentioned that the patient had a fall in early 2/2016 due to left lower extremity numbness and is continuing

The patient has a history of discectomy to the left with temporary improvement of his lumbar pain and lower extremity symptoms. He has reherniation to the left correlating to the L4-L5. He has had transforaminal epidural steroid injections and facet injections with relief of his lumbar pain.

Based on the medical report dated 02/01/16, the patient presents for a routine follow-up visit regarding her chronic neck pain with radiation down the left upper extremity into the thumb with numbness and tingling. She reports no change in her pain since her last follow-up visit. She states she stopped taking the Lyrica because it was making her feel weird and her head felt cloudy. She did wean off of it as instructed without problems. Authorization for acupuncture treatments was denied by the insurance because it stated the left hand pain was not part of her claim. Patients hand pain only developed after she had the neck surgery, which was anterior cervical discectomy and fusion (ACDF) at C5-C6.

A lumbar fracture is a break in one of the bones of the lower back. Lumbar fractures range in severity. Severe fractures can damage the spinal cord.

Clinical Scenario: Adult female accountant complaints of right-sided lateral upper extremity numbness and tingling, pain, weakness, and dropping things held in right hand.

DOI: 10/11/2001. Patient is a 51-year-old female tandem system operator who sustained a work-related injury while she was pushing sleeve off the top deck and felt muscle pull in low back and left leg. Per OMNI, she underwent laminectomy and discectomy on 7/23/2002 and another decompression laminectomy on 8/28/2007. She had dorsal column stimulator surgery on 10/14/2008 and reposition on 3/9/2009. This was then removed in November of 2010.

Fracture or damage to the Lumbar vertebrae 5 may result into "foot drop with weakness of the anteriortibial, postiriortibial, loss of function by the peroneal muscle, and the damage to the sacral vertebrae 1 may result into weakness of the medial gastrocnemius muscle with impaired ankle planter flexion and loss of ankle