CLINICAL SUMMARY:
DOI: 5/11/2012. Patient is a 48-year old male truck driver who sustained a work-related injury to his back when he was rear ended by another party. Patient is status post bilateral L3-L4 and L4-L5 left-sided and sublaminar laminotomy with neuroforaminotomy; and synovial facet cyst resection at left L4-L5 per the operative report dated 04/20/15.
MRI of the lumbar spine dated 02/03/16 revealed transitional lumbosacral junction, sacralized L5 and rudimentary L5-S1 disc; left laminectomy at L3-L4; and early degenerative disc disease and slight bulging of the disc at L3-4 and L4-5.
Per the AME report dated 03/17/16, it was noted that should all conservative measures fail to relieve symptoms, further surgical consideration would be appropriate and would consist of a lumbar fusion. Consideration of an …show more content…
He notes tingling down the posterior legs with numbness along the left leg to the foot and more recently some numbness to the right lower leg and foot. He has continued with his home exercise program (HEP), and has noticed with back rowing exercises, he will experience a sharp shooting pain down the right leg. He continues to be limited in activity due to his symptoms, as any increase in activity leads to an increase in symptoms. He is frustrated with his ongoing complaints.
On examination, there is tenderness over the lumbar paraspinals. There is pain with lumbar flexion and extension. Sensation is diminished to light touch over the left L5 and S1 dermatomes.
Patient was diagnosed with status post bilateral L3-5 decompressive laminotomy and lumbar radiculitis versus radiculopathy.
It was noted that the IW continues to experience lower extremity symptomatology despite conservative treatment and he is frustrated with his lack of improvement. MD continues to believe that he is a proper surgical candidate and would benefit from revision L4-S1 decompressive bilateral
DOI: 5/11/2012. Patient is a 48-year old male truck driver who sustained a work-related injury to his back when he was rear ended by another party. Patient is status post bilateral L3-L4 and L4-L5 left-sided and sublaminar laminotomy with neuroforaminotomy; and synovial facet cyst resection at left L4-L5 per the operative report dated 04/20/15.
MRI of the lumbar spine dated 02/03/16 revealed transitional lumbosacral junction, sacralized L5 and rudimentary L5-S1 disc; left laminectomy at L3-L4; and early degenerative disc disease and slight bulging of the disc at L3-4 and L4-5.
Per the AME report dated 03/17/16, it was noted that should all conservative measures fail to relieve symptoms, further surgical consideration would be appropriate and would consist of a lumbar fusion. Consideration of an …show more content…
He notes tingling down the posterior legs with numbness along the left leg to the foot and more recently some numbness to the right lower leg and foot. He has continued with his home exercise program (HEP), and has noticed with back rowing exercises, he will experience a sharp shooting pain down the right leg. He continues to be limited in activity due to his symptoms, as any increase in activity leads to an increase in symptoms. He is frustrated with his ongoing complaints.
On examination, there is tenderness over the lumbar paraspinals. There is pain with lumbar flexion and extension. Sensation is diminished to light touch over the left L5 and S1 dermatomes.
Patient was diagnosed with status post bilateral L3-5 decompressive laminotomy and lumbar radiculitis versus radiculopathy.
It was noted that the IW continues to experience lower extremity symptomatology despite conservative treatment and he is frustrated with his lack of improvement. MD continues to believe that he is a proper surgical candidate and would benefit from revision L4-S1 decompressive bilateral