Raadiculopathy: A Case Study

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

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.

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

02/09/16 Progress Report noted that the patient has neck pain, upper back pain, and shooting pain down the arms. The pain is on the left side. It is rated as 3-4/10. It is stabbing, burning, and pins and needles. Medications and rest alleviate the pain. Work, standing, walking, and activity aggravate it. The patient has tried muscle relaxants, strong pain meds, PT, hot packs, and ice, all of which have helped, but he continues to experience substantial pain. The exam revealed that the DTRs were mildly diminished in the left upper extremity.

Per the IME report on 4/28/16 by Dr. Pierce Ferriter, the patient reports that he is actively treating with physical therapy and chiropractic treatment at a frequency of 3 to 4 times per week. The patient’s diagnoses include resolved lumbar strain, resolved cervical strain, resolved left shoulder strain and resolved right knee strain. There is no medical necessity for further physical therapy, orthopedic treatment of diagnostic testing based on examination.

On the statement of medical necessity per MG-2 form dated 07/13/16, patient has been experiencing severe lumbar spine pain/spasms since the injury. She complains of lumbar spine pain with cramps in the lower extremity going down to the feet, associated with tingling sensation. There is left greater than right L3-S1 pain and spasms, left greater than the right L3-4, L4-5 and L5-S1 facet joint pain, upon posterolateral extension at 45 degrees. There is bilateral sacroiliac joint tenderness. There is tenderness over the right lateral quadriceps muscle. Range of motion (ROM) is limited secondary to

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.

MRI scan of the lumbar spine with contrast dated 7/17/2015 showed compression of the descending left L5 nerve root at L5-S1 on the basis of a 6.1mm left paracentral disc extrusion and compression of the descending left L4 nerve root at L3-L4 on the basis of a 6mm left-sided pre-foraminal and foraminal disc extrusion.

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 latest follow-up physiatric evaluation report dated 01/11/16, the patient complains of lower back pain which improves temporarily with PT but continues to radiate to his left leg with numbness, tingling and weakness. He attends PT three days per week and participates in a daily home exercise program.

Based on the progress report dated 03/28/16, the patient complains of pain to his lumbar

DOI: 12/19/2015. Patient is a 23-year-old male field technician who sustained injury while removing a ladder from a truck. Per OMNI, he was initially diagnosed with back sprain/strain.

In addition to the complaint of low back, this patient may be exhibited signs and symptoms associated with L4-L5 disk herniation and to a lesser extent L5-S1 disk herniation. This area is the most common place for a disc to herniate, on the account of the amount of weight these vertebral segments carry and due to their range of motion. A disk herniation at the L4-L5 can cause nerve root impingent resulting in a L5 radiculopathy. The symptoms that arise from a radiculopathy can cause an array of symptoms. In addition to the low back pain, pain may radiate into the buttock and down the leg and into the foot. Neurological symptoms can include muscle weakness, parasthesia, and sensory loss in dermatomal distribution. For the L5 nerve root this

The patient is diagnosed with herniated lumbar disc, lumbar canal stenosis, lumbar disc degeneration, lumbar radiculopathy, postlaminectomy syndrome (lumbar), and lower back pain.