Lmbar Discogenic Pain Syndrome Case Studies

DOI: 11/16/2015. Patient is a 53-year-old male employee who sustained injury while he was walking and cleaning hand rails when he slipped and fell. He had a lumbar strain. The patient is subsequently diagnosed with lumbar Discogenic pain syndrome; lumbar radiculitis; numbness, chronic bilateral low back pain with sciatica, sciatica laterality unspecified; and myalgia. MRI of the cervical spine dated 1/28/16 (no official report) revealed that C3-4 and C4-5 mild broad-based posterior disc bulge. MRI of the thoracic spine dated 1/28/16 (no official report) revealed that T9-10 left facet arthrosis and focal ligamentum flavum height atrophy is causing moderate narrowing of the central canal posteriorly on the left and causing mild indentation on the posterior surface of the …show more content…
He was treated with 8 sessions of physical therapy. He consulted with Dr. Hambly on 6/5/16. He is here for another opinion on his situation. Dr. Hambly did not feel he was an optimal surgical candidate at that time. The patient is frustrated with his symptoms and feels he is very limited due to his pain. Previous treatment includes 8 sessions of physical therapy in December 2015, aspirin, and Motrin. Current medications include ibuprofen 200 mg, simvastatin 20 mg, Lisinopril 5 mg, Januvia 100 mg, aspirin 81 mg, metformin 500 mg, and glimperide 2 mg. Review of systems revealed night sweats, blurry vision, joint pain, muscle pain, muscle weakness, depression and anxiety. Physical examination revealed blood pressure of 135/84. Musculoskeletal/neurological examination revealed patellar reflexes are 2+. His strength is 5/5 in the lower extremities except extensor hallucis longus (EHL). He has decreased sensation in the L5 dermatome. Low back examination revealed that he has tenderness to palpation over the thoracolumbar paraspinals bilaterally. Straight leg raising is positive bilaterally eliciting pain in the L5 dermatome. He has lumbar flexion to 45 degrees with