Radiculopathy Case Studies

MRI of the cervical spine obtained on 06/26/13 showed mild degenerative spondylitic changes and status post posterior fusion.

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

Per medical report dated 11/24/15 by Dr. Cano, the patient is complaining of severe numbness in the right hand, tightness around the right worse than left hand. She also associates this with dropping items. She is unable to button her shirts or raise her arms up to her elbows. This is continuous all day long. Also, associated is severe low back pain with numbness, radiation, and muscle spasm in the thoracic area, and numbness and radiation down the right sciatic nerve with severe low back pain. She continued to work, sixteen-hour shifts, seven days a week. At this time, she is unable to function. She states that she has had 24 sessions of physical therapy that has definitely helped her.

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

Mcclurg, the patient presents for his neck pain, described as dull and aching. Treatment to date includes activity modification, acupuncture, and 9 sessions of chiropractic care. Condition is improving. Current care has provided 70% pain relief. Of note, MRI of the cervical spine dated 3/25/2015 revealed C5-6 discogenic spondyloarthropathy with mild central canal stenosis and mild bilateral C4-5 facet arthrosis.

MRI of the cervical spine dated 08/17/16 showed at C3-4 and C4-5, there is mild posterior disc bulging.

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.

X-rays of the lumbar spine dated 11/6/2015 revealed mild loss of the disc heights at L4-L5 and posteriorly at L5-S1 level, consistent with degenerative disc disease. There are also anterior endplate osteophytes at

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

As per office notes dated 5/4/16, the patient is seen for bilateral elbow pain and bilateral wrist pain. She rates the pain as 3/10 with medication and 7/10 without medication. She is active for at least six hours a day and has energy to make plans. Her activity level has

Based on the latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

DOI: 10/14/2009. Patient is a 44-year-old female hospital medical records clerk who sustained a work-related injury after tripping over a garbage can and fell on her right knee.

01/26/16 Progress Report noted that the patient presented with left shoulder pain. The pain was gradual in onset and is constant. The pain is characterized as burning, sharp, shooting, and throbbing. It radiates to the neck. She described her pain as moderate to severe. Her condition is associated with numbness in her left fingertips and weakness in her upper extremities. Any activity, movement and reaching aggravate the pain. Stretching and hot showers relieve the pain. The level of sleep has been decreased due to difficulty falling asleep. The quality of sleep is poor. She has difficulty performing her ADLs. Current medications: Meloxicam, Naproxen, and Spironolactone. Review of Systems was positive for weakness and nausea. The patient also has anxiety and depression. She has had psychiatric, psychological, or social work evaluations or treatments for problems. The physical exam of the cervical spine revealed that the ROM is restricted. There were spasms and tenderness of the paravertebral muscles bilaterally. There was also spinous process tenderness noted on C6 and C7. Tenderness is noted at the paracervical muscles and trapezius. Spurling’s maneuver produces no pain in the neck muscles or radicular symptoms in the arm. Adson’s test is negative. No signs of meningism. Cervical facet loading is negative on both sides. The exam of the right shoulder was

Based on the medical report dated 04/11/16 by Dr. Au, the patient complains of neck pain and presents for a cervical epidural steroid injection. Pain is rated as 5/10 and described as stiff, tight and achy. Pain is worse with turning his head. He continues to do PT for his neck pain and shoulders with benefit.

Based on the medical report dated 02/08/16, the patient reports ongoing right wrist and elbow pain. She rates her wrist and hand pain 6-7/10 and right elbow pain 5/10 in severity. The pain becomes worse with movements of her right wrist or grabbing objects. She has to keep her right arm against her torso when walking as arm swinging increases her arm pain. She takes naproxen twice a day and omeprazole 20 mg 1-2 capsules a day. Naproxen 550 mg lowers her wrist and elbow pain