DOI: 11/8/2004. Patient is a 56-year-old male central processing technician who sustained cumulative trauma to his wrists and cervical spine. As per OMNI, he is diagnosed with cervical disc disease and bilateral carpal tunnel syndrome. He underwent a cervical ESI on 03/31/10. He is status post cervical fusion on 9/15/11 and status post carpal tunnel releases.
MRI of the cervical spine obtained on 05/19/14 demonstrated no significant interval change compared to prior study. Anterior fusion with hardware is noted in place at C4-C7 with patent central canal and no cord compression. Multilevel mild to moderate neural foraminal narrowing is stable.
CT of the cervical spine performed on 05/19/14 revealed postsurgical findings of anterior fusion with hardware in place at C4-C5, C5-C6 and C6-C7 with solid fusion. The central canal is patent. Multi-level mild to moderate neural foraminal narrowing is noted.
EMG and nerve conduction study performed on 12/31/09 revealed no evidence of a left or right sided cervical radiculopathy.
Based on the visit note dated 12/21/15, the patient complains of severe neck pain and upper extremity …show more content…
He has a large surgical scar which is well-healed cervical region. He has decreased range of motion secondary to his cervical fusion. He has a positive Tinel’s on the right. Current medications include Colace, Lidoderm 5% patch, Mobic, Ketamine 5% cream, gabapentin, tizanidine, morphine sulfate extended release (ER) 60 mg 1 tablet every 8 hours, Albuterol 0.083% and pseudoephedrine. Diagnoses are cervicalgia, low back pain, left trigger thumb and long term (current) use of opiate analgesic. He was given a prescription for morphine sulfate ER 30 mg 1 tablet daily at noon, morphine sulfate ER 60 Mg 1 tablet in the morning and 1 tablet in the evening and tizanidine 4 mg. Treatment plan includes a bilateral cervical facet joint injection under intravenous
MRI of the cervical spine obtained on 05/19/14 demonstrated no significant interval change compared to prior study. Anterior fusion with hardware is noted in place at C4-C7 with patent central canal and no cord compression. Multilevel mild to moderate neural foraminal narrowing is stable.
CT of the cervical spine performed on 05/19/14 revealed postsurgical findings of anterior fusion with hardware in place at C4-C5, C5-C6 and C6-C7 with solid fusion. The central canal is patent. Multi-level mild to moderate neural foraminal narrowing is noted.
EMG and nerve conduction study performed on 12/31/09 revealed no evidence of a left or right sided cervical radiculopathy.
Based on the visit note dated 12/21/15, the patient complains of severe neck pain and upper extremity …show more content…
He has a large surgical scar which is well-healed cervical region. He has decreased range of motion secondary to his cervical fusion. He has a positive Tinel’s on the right. Current medications include Colace, Lidoderm 5% patch, Mobic, Ketamine 5% cream, gabapentin, tizanidine, morphine sulfate extended release (ER) 60 mg 1 tablet every 8 hours, Albuterol 0.083% and pseudoephedrine. Diagnoses are cervicalgia, low back pain, left trigger thumb and long term (current) use of opiate analgesic. He was given a prescription for morphine sulfate ER 30 mg 1 tablet daily at noon, morphine sulfate ER 60 Mg 1 tablet in the morning and 1 tablet in the evening and tizanidine 4 mg. Treatment plan includes a bilateral cervical facet joint injection under intravenous