The patient is a 62-year-old individual who sustained an injury on 05/01/11. The mechanism of injury was not documented in the reports reviewed.
The patient was diagnosed with intervertebral disc disorders with radiculopathy in the lumbosacral region, intervertebral disc disorders with radiculopathy in the lumbar region, and pain disorder with related psychological factors.
Prior treatments included physical therapy, home exercise program, chiropractic treatment, acupuncture with some benefits, the use of a knee brace, walker, and medications. The patient underwent a spine injection (undated) with noted pain relief. The patient also underwent a transforaminal lumbar epidural injection (undated). Current medications included Gabapentin