DOI: 5/12/2004. The patient is a 54-year old male night stocker who sustained a work-related injury to his mid back and neck while pushing a product.
Per the medical report dated 10/10/15, the patient still has severe neck pain with pain radiating down arms, as well as back pain and numbness in both legs.
MRI of the cervical spine dated 10/30/2015 demonstrated degenerative spondylotic changes at C3-4 through C6-7 with multi-level central canal stenosis. There is also narrowing and increased T2 signal intensity at C4-5 with a ventral epidural mass effect or collection of uncertain significant producing moderate cord compression. Post-gadolinium-enhanced MR imaging is recommended along with cervical CT scanning for further evaluation.
MRI …show more content…
He said his neck pain is worse than his bilateral arm pain.
On motor examination, he has no arm drift. He has full strength in his bilateral grips interossei, finger extensors, wrist flexion, wrist extension, brachioradialis, biceps, triceps and deltoids.
Light touch sensation is symmetrical in all dermatomes of his bilateral upper extremities. patient is obese
Current medications include atenonol, omeprazole, metaxalone, hydrocodone, gabapentin, ibuprofen and Ventolin.
Assessment is cervical disc disorder with radiculopathy. As of this report, MRI cervical spine reveals a large C4-5 disc herniation extending caudally behind the C5 vertebral body. MD believes she will benefit from a C4-5 anterior cervical discectomy and fusion. Because of the caudal migration of his disc herniation, he may require a full C5 corpectomy with C4-C6 anterior cervical fusion with instrumentation.
Requested verification from the provider’s office on the IW’s conservative treatments to date and requested for reports, as well as X-ray report; however, no callback/report was received prior to the submission of this request to
Per the medical report dated 10/10/15, the patient still has severe neck pain with pain radiating down arms, as well as back pain and numbness in both legs.
MRI of the cervical spine dated 10/30/2015 demonstrated degenerative spondylotic changes at C3-4 through C6-7 with multi-level central canal stenosis. There is also narrowing and increased T2 signal intensity at C4-5 with a ventral epidural mass effect or collection of uncertain significant producing moderate cord compression. Post-gadolinium-enhanced MR imaging is recommended along with cervical CT scanning for further evaluation.
MRI …show more content…
He said his neck pain is worse than his bilateral arm pain.
On motor examination, he has no arm drift. He has full strength in his bilateral grips interossei, finger extensors, wrist flexion, wrist extension, brachioradialis, biceps, triceps and deltoids.
Light touch sensation is symmetrical in all dermatomes of his bilateral upper extremities. patient is obese
Current medications include atenonol, omeprazole, metaxalone, hydrocodone, gabapentin, ibuprofen and Ventolin.
Assessment is cervical disc disorder with radiculopathy. As of this report, MRI cervical spine reveals a large C4-5 disc herniation extending caudally behind the C5 vertebral body. MD believes she will benefit from a C4-5 anterior cervical discectomy and fusion. Because of the caudal migration of his disc herniation, he may require a full C5 corpectomy with C4-C6 anterior cervical fusion with instrumentation.
Requested verification from the provider’s office on the IW’s conservative treatments to date and requested for reports, as well as X-ray report; however, no callback/report was received prior to the submission of this request to