DOI: 10/20/2009. Patient is a 43-year-old male maintenance technician who sustained injury after lifting a manhole. Per OMNI entry, he is status post lumbar discectomy and foraminotomy on 01/25/2010 and repeat L5-S1 discectomy and foraminotomy on 02/28/2013.
Based on the latest medical report dated 11/03/16 by Dr. Wensel, the patient presents with intermittent shooting left leg pain that occurs several times a week. It goes down the posterior-lateral leg to the foot. There is numbness on the lateral aspect of his left foot. He will also has sharp pain on the bottom of the foot as well. After his last visit, he developed severe right side lower back pain with radiation to the buttock and groin. He states that he missed several days of work. He was referred to see a pain management specialist. He was prescribed meloxicam, that he …show more content…
Minor's sign is not present.
Muscle strength testing shows 4/5 over the left dorsiflexors and external hallucis longus. Gait is narrow-based and steady.
Current medications include Flexeril, Mobic, Famvir and Loprox.
Spinal X-rays of the lumbar spine performed on 11/01/16 revealed mild L4-5 and L5-S1 disc space narrowing.
MRI of the lumbar spine performed on 11/01/16 showed a left paracentral disc extrusion, facet arthropathy, and thickening of the ligamentum flavum at L4-L5 which result in severe narrowing of the spinal canal, compression and deformity of the thecal sac as well as narrowing of the left lateral recess.
At L5-S1 level, there is a broad-based central and left paracentral disc protrusion and facet arthropathy. There is slight narrowing of left lateral recess. Central canal is otherwise patent. Mild narrowing of bilateral neural foramen is seen.
Impression is refractory left L5 radiculopathy from a large left L4/5 herniated disc. Surgery is recommended by way of a left L4/5 minimally invasive discectomy to address his refractory
Based on the latest medical report dated 11/03/16 by Dr. Wensel, the patient presents with intermittent shooting left leg pain that occurs several times a week. It goes down the posterior-lateral leg to the foot. There is numbness on the lateral aspect of his left foot. He will also has sharp pain on the bottom of the foot as well. After his last visit, he developed severe right side lower back pain with radiation to the buttock and groin. He states that he missed several days of work. He was referred to see a pain management specialist. He was prescribed meloxicam, that he …show more content…
Minor's sign is not present.
Muscle strength testing shows 4/5 over the left dorsiflexors and external hallucis longus. Gait is narrow-based and steady.
Current medications include Flexeril, Mobic, Famvir and Loprox.
Spinal X-rays of the lumbar spine performed on 11/01/16 revealed mild L4-5 and L5-S1 disc space narrowing.
MRI of the lumbar spine performed on 11/01/16 showed a left paracentral disc extrusion, facet arthropathy, and thickening of the ligamentum flavum at L4-L5 which result in severe narrowing of the spinal canal, compression and deformity of the thecal sac as well as narrowing of the left lateral recess.
At L5-S1 level, there is a broad-based central and left paracentral disc protrusion and facet arthropathy. There is slight narrowing of left lateral recess. Central canal is otherwise patent. Mild narrowing of bilateral neural foramen is seen.
Impression is refractory left L5 radiculopathy from a large left L4/5 herniated disc. Surgery is recommended by way of a left L4/5 minimally invasive discectomy to address his refractory