DOI: 07/23/2002. This is a case of 57-year-old male custodian who sustained injury to his low back while lifting wrestling mats.
The patient was subsequently diagnosed with radiculopathy, lumbosacral region; myalgia; and long term (current) use of opiate analgesic.
As per office notes dated 5/9/16, the patient complained of chronic pain in his lumbar spine. He states that the pain increases with activity.
He needs Tramadol occasionally to control his pain and perform his work duties. He continues to work full duty. He has daily exacerbation of pain as the day progresses and he is involved in activities.
He said that it is difficult to rest with the pain in back and legs. Gabapentin helps a little; however, he avoids increase in dose due to dizziness. The patient mentions that he does not want surgery or procedures. There are also moderate/severe back pains with worsened weakness in his legs. Pain is worse at night and medication help with sleep and pain. Physical examination observed pain behaviors, such as frequent shifting of posture or position, sitting with a rigid posture and extended left leg and slouched position in the chair. He has slowed gait and cannot perform single leg stance without loss of balance. Physical examination of lumbar spine revealed that the range of motion of lumbar spine is restricted, with flexion limited to 50 degrees, and extension of 15 degrees. …show more content…
Spinous process tenderness is noted on L4 and L5. Straight leg raising test is positive on the bilateral sides at 50
The patient was subsequently diagnosed with radiculopathy, lumbosacral region; myalgia; and long term (current) use of opiate analgesic.
As per office notes dated 5/9/16, the patient complained of chronic pain in his lumbar spine. He states that the pain increases with activity.
He needs Tramadol occasionally to control his pain and perform his work duties. He continues to work full duty. He has daily exacerbation of pain as the day progresses and he is involved in activities.
He said that it is difficult to rest with the pain in back and legs. Gabapentin helps a little; however, he avoids increase in dose due to dizziness. The patient mentions that he does not want surgery or procedures. There are also moderate/severe back pains with worsened weakness in his legs. Pain is worse at night and medication help with sleep and pain. Physical examination observed pain behaviors, such as frequent shifting of posture or position, sitting with a rigid posture and extended left leg and slouched position in the chair. He has slowed gait and cannot perform single leg stance without loss of balance. Physical examination of lumbar spine revealed that the range of motion of lumbar spine is restricted, with flexion limited to 50 degrees, and extension of 15 degrees. …show more content…
Spinous process tenderness is noted on L4 and L5. Straight leg raising test is positive on the bilateral sides at 50