DOI: 10/23/2006. Patient is a 69-year-old male assistant terminal manager/superintendent who alleges numerous work related injuries to his back, right shoulder and left elbow due to cumulative trauma.
Per IME report dated 01/22/09, the patient has had microforaminotomies of the lumbar spine. Medications include Gabapentin, doxazosin, Vicodin and Celebrex. It was opined that the patient has reached maximum medical improvement.
Per procedure reports, the patient underwent a bilateral L3-L4 medial branch radiofrequency ablation on 11/14/13, and a right L4-5 and L5-S1 intraarticular facet block on 03/25/14. Lumbar SPECT-scan was obtained on 03/13/14 which showed greatest activity seen in the L4-5 facets, right greater than the left, corresponding to facet arthrosis. There is a mild activity seen on the left at the anterior aspect of the L5-S1 interspace corresponding to degenerative spondylosis. …show more content…
His back condition has responded well to periodic radiofrequency procedures to treat his bilateral L4-5 facet inflammation. His last procedure was on 09/2015. His radicular symptoms have been under control with Neurontin. He also takes Cymbalta and Norco. He presents with new right posterolateral hip pain that feels distinctly different from his typical chronic low back pain and radicular symptoms. Pain has been gradually worsening since December. He cannot identify a specific injury as a precipitating factor. Intensity is 8-10/10. Pain worsens with standing, walking, climbing stairs, getting in and out of tall vehicles, lying down and prolonged sitting. Pain is described as stinging with walking and aching with sitting. He has tried heat, ice and Capsaicin cream without relief. Patient has had previous, extensive PT without improvement in his low back
Per IME report dated 01/22/09, the patient has had microforaminotomies of the lumbar spine. Medications include Gabapentin, doxazosin, Vicodin and Celebrex. It was opined that the patient has reached maximum medical improvement.
Per procedure reports, the patient underwent a bilateral L3-L4 medial branch radiofrequency ablation on 11/14/13, and a right L4-5 and L5-S1 intraarticular facet block on 03/25/14. Lumbar SPECT-scan was obtained on 03/13/14 which showed greatest activity seen in the L4-5 facets, right greater than the left, corresponding to facet arthrosis. There is a mild activity seen on the left at the anterior aspect of the L5-S1 interspace corresponding to degenerative spondylosis. …show more content…
His back condition has responded well to periodic radiofrequency procedures to treat his bilateral L4-5 facet inflammation. His last procedure was on 09/2015. His radicular symptoms have been under control with Neurontin. He also takes Cymbalta and Norco. He presents with new right posterolateral hip pain that feels distinctly different from his typical chronic low back pain and radicular symptoms. Pain has been gradually worsening since December. He cannot identify a specific injury as a precipitating factor. Intensity is 8-10/10. Pain worsens with standing, walking, climbing stairs, getting in and out of tall vehicles, lying down and prolonged sitting. Pain is described as stinging with walking and aching with sitting. He has tried heat, ice and Capsaicin cream without relief. Patient has had previous, extensive PT without improvement in his low back