DOI: 2/11/2014. Patient is a 35-year-old male installation technician who sustained injury when he slipped and fell on staircase. Per OMNI, he sustained contusion to right elbow/back. He had a lumbar caudal epidural steroid injection on 6/28/2014.
MRI of the lumbar spine obtained on 3/27/2014 revealed L5/S1 broad right paramedian posterior disc herniation impressing and posteriorly displacing the right S1 nerve root after it exits the thecal sac flattening the contour of the ventral margin of the right S1 nerve root and impressing it against the right facet at this level. There is radial annular tear. The posterolateral component of the disc herniation encroaches also toward the foramen to a lesser degree. There is L1/2 right posterior subligamentous disc herniation impressing on the right …show more content…
His lower back is intermittent in nature and radiates down to his bilateral lower extremities. His MRIs have shown degeneration and loss of disc height at L4-5 and L5-S1. There is also a disc herniation at L5-S1. He has also had a discogram that was concurrent at L4-5 and L5-S1. His CT shows fissures and tears at both levels. He is currently unable to work and carry on with daily activities. He has recently gotten approval for L4-5 and L5-S1 transforaminal lumbar interbody fusion (TLIF). He is waiting for the letter.
On examination, there is limited range of motion in regards to lumbar flexion and extension. There is some tenderness to palpation to the lumbar spine.
Diagnoses are lumbar region intervertebral disc displacement and lumbar spondylosis without myelopathy and radiculopathy. It was noted that once he receives his approval letter, surgery will be scheduled.
Per the IME report by Dr. Singh dated 05/20/15, there is no medical necessity for further causally related treatment, diagnostic testing or follow-up in neurology. There is also no medical necessity for
MRI of the lumbar spine obtained on 3/27/2014 revealed L5/S1 broad right paramedian posterior disc herniation impressing and posteriorly displacing the right S1 nerve root after it exits the thecal sac flattening the contour of the ventral margin of the right S1 nerve root and impressing it against the right facet at this level. There is radial annular tear. The posterolateral component of the disc herniation encroaches also toward the foramen to a lesser degree. There is L1/2 right posterior subligamentous disc herniation impressing on the right …show more content…
His lower back is intermittent in nature and radiates down to his bilateral lower extremities. His MRIs have shown degeneration and loss of disc height at L4-5 and L5-S1. There is also a disc herniation at L5-S1. He has also had a discogram that was concurrent at L4-5 and L5-S1. His CT shows fissures and tears at both levels. He is currently unable to work and carry on with daily activities. He has recently gotten approval for L4-5 and L5-S1 transforaminal lumbar interbody fusion (TLIF). He is waiting for the letter.
On examination, there is limited range of motion in regards to lumbar flexion and extension. There is some tenderness to palpation to the lumbar spine.
Diagnoses are lumbar region intervertebral disc displacement and lumbar spondylosis without myelopathy and radiculopathy. It was noted that once he receives his approval letter, surgery will be scheduled.
Per the IME report by Dr. Singh dated 05/20/15, there is no medical necessity for further causally related treatment, diagnostic testing or follow-up in neurology. There is also no medical necessity for