DOI: 11/22/2006. Patient is a 55-year-old male route sales representative who sustained injuries to his right elbow, shoulder, neck and back while he was exiting a truck and he stepped on the bumper, when the bumper collapsed.
MRI of the lumbar spine performed on 03/31/16 showed disc herniations at L3-S1 deforming the thecal sac with bilateral neural foraminal extension at all three levels, abutting the exiting L5 nerve roots with left neural foraminal narrowing at L5-S1, left greater than right abutting the exiting left L4 nerve root at L4-5, and right greater than left, abutting the exiting right L3 nerve roots at L3-4 in addition to L4-5 and L5-S1 grade I spondylolisthesis, and L3-4 and L4-5 mild central spinal stenosis in conjunction …show more content…
He has more difficulty bending and extending the lumbar spine. He is requesting intervention for relief because he is finding less relief with pain medication. Patient last had interventions several months ago. He had right lumbar facet joint radiofrequency ablation done on 12/15/2015 and lumbar facet injections done in …show more content…
IW is using Oxycontin 20mg twice daily and Percocet 5/325mg twice daily.
The patient reports that he also continues to have occasion al radiation of the pain from the right buttock, down the right lower extremity to the calf. He has had baseline numbness in his right foot, since his accident. Back pain is described as constant as aching and throbbing with sharp exacerbations. Pain is rated 3.5/10. Pain is worsened with bending, lifting and working; and alleviated with rest, stretching and pain medications.
Current medications include Oxycontin, Percocet, Lorzone, topical diclofenac, chlorzoxazone, and Advil.
The patient has had lumbar facet blocks, and lumbar radiofrequency ablation in the past with good improvement of both the axial and radicular symptoms.
On examination of the lumbar spine, there is midline tenderness.
Range of motion shows flexion of 75 degrees with mild discomfort and pain with return to neutral, extension is less than 10 degrees with pain, and bilateral bend/rotation with pain. There is multifidus diffuse pain on palpation. Multiple trigger points are palpable, bilaterally. Quadratus lumborum muscles tenderness is noted on palpation, with palpable trigger points,
MRI of the lumbar spine performed on 03/31/16 showed disc herniations at L3-S1 deforming the thecal sac with bilateral neural foraminal extension at all three levels, abutting the exiting L5 nerve roots with left neural foraminal narrowing at L5-S1, left greater than right abutting the exiting left L4 nerve root at L4-5, and right greater than left, abutting the exiting right L3 nerve roots at L3-4 in addition to L4-5 and L5-S1 grade I spondylolisthesis, and L3-4 and L4-5 mild central spinal stenosis in conjunction …show more content…
He has more difficulty bending and extending the lumbar spine. He is requesting intervention for relief because he is finding less relief with pain medication. Patient last had interventions several months ago. He had right lumbar facet joint radiofrequency ablation done on 12/15/2015 and lumbar facet injections done in …show more content…
IW is using Oxycontin 20mg twice daily and Percocet 5/325mg twice daily.
The patient reports that he also continues to have occasion al radiation of the pain from the right buttock, down the right lower extremity to the calf. He has had baseline numbness in his right foot, since his accident. Back pain is described as constant as aching and throbbing with sharp exacerbations. Pain is rated 3.5/10. Pain is worsened with bending, lifting and working; and alleviated with rest, stretching and pain medications.
Current medications include Oxycontin, Percocet, Lorzone, topical diclofenac, chlorzoxazone, and Advil.
The patient has had lumbar facet blocks, and lumbar radiofrequency ablation in the past with good improvement of both the axial and radicular symptoms.
On examination of the lumbar spine, there is midline tenderness.
Range of motion shows flexion of 75 degrees with mild discomfort and pain with return to neutral, extension is less than 10 degrees with pain, and bilateral bend/rotation with pain. There is multifidus diffuse pain on palpation. Multiple trigger points are palpable, bilaterally. Quadratus lumborum muscles tenderness is noted on palpation, with palpable trigger points,