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Raadiculopathy: A Case Study

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This is a 48-year-old male with a 6/7/1995 date of injury. A specific mechanism of injury has not been described.

DIAGNOSIS: Intervertebral disc disorder with radiculopathy lumbar region. HNP lumbar.

01/15/16 Progress Report noted that the patient has lower back pain and left leg pain. It was noted that the provider spoke with the patient over the phone. He has continuing pain in the right lower extremity. The epidural injections have been denied. He has a herniated disc on the right L2-3. He has been suffering from symptoms in the right leg for the last 5 months. He cannot tolerate the pain. He would like to pursue surgery. The examination of the thoracic spine was normal. The exam of the lumbosacral spine showed that all musculature
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The ROM was restricted, 50% of normal. The paraspinal muscle strength and tone was normal. The SLR was negative bilaterally. The exam of the left lower extremity was normal. The exam of the right lower extremity was normal except mild decreased strength in the right hip flexors. A reported MRI Lumbar Imaging on 07/01/15 showed multilevel degenerative changes; Previous L4 to sacrum fusion, evidence of herniated disc or significant central stenosis or foraminal stenosis. A reported MRI L Spine on 11/05/15 revealed herniated disc L2-3 with inferior extrusion impinging on the right L3 nerve root. Assessment: The patient has continuing symptoms of pain in the right lower extremity radiating down along the anterior thigh. This is consistent with the herniated disc at the L2-3 level on the right. He had previous surgery at the L2-3 level 3 years ago for his work-related…show more content…
He returned to see Dr. Kahmann and underwent further diagnostic studies. Approximately eight months ago, he underwent a two-level decompression. However, about three months after that, he was taken back to surgery for redo decompression at L2-3. Currently, there is constant burning pain in his left lower extremity along with hyposthesia and weakness. He finds it difficult to sleep at night because of his pain. Lumbar spine examination revealed well-healed anterior and posterior surgical scars. Lower extremity neurological examination revealed decreased sensation in the L2, L3, L4, L5 and S1 dermatomes. There was 4+/5 to 5-/5 strength in the left peroneals and left EHL, and an absent left AJ reflex. The SLR is positive on the left. Lasegue maneuver and femoral stretch are negative. Gait is waddling. Unable to heel walk on the left. Able to toe walk with some difficulty on the left. Lumbar ROM was significantly reduced. The patient is currently
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