DOI: 2/13/2015. The patient is a 48-year-old male driver who sustained a work-related injury after getting involved in a motor vehicle accident while making a delivery. Per OMNI entry, the patient has been diagnosed with head contusion and cheek/neck injury.
MRI of the lumbar spine dated 05/22/2015 showed very small disc bulges and early facet arthropathy along the spine with very shallow posterior disc herniations at L3-4 and L5-S1, which causes no significant spinal canal and foraminal narrowing.
Per the operative report dated 06/26/15, the patient underwent a lumbar transforaminal epidural steroid injection at the bilateral L5-S1 levels.
Per medical report dated 07/13/2015, the patient stated that the injection helped but he is still
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He is taking pain medications, which do not help to take the edge off his symptoms. Pain is rated as 7/10 with medications. He states that his symptoms have not changed from his last visit.
On examination of the lumbar spine, lordosis is decreased. There is tenderness of the paraspinal region at L5 bilaterally, and at the right sacroiliac joint. Active range of motion (ROM) shows flexion of 50 degrees and extension of 5 degrees, with pain. Motor strength shows 4/5 with right ankle dorsiflexion tibialis anterior and great toe extension extensor hallucis longus. Sensation is decreased over the lateral leg and dorsum of the foot. There is atrophy of the right calf.
Current medications include gabapentin and Norco.
IW was diagnosed with low back pain, lumbar disc annular tear, intervertebral disc annulus fibrosus tear, spinal facet joint arthropathy, lumbar discogenic pain.
Treatment plan includes pain management referral and right L5-S1 Epidural Steroid Injection (ESI).
Per verification to the PT facility, the patient has attended 2 PT sessions for the lower back from 04/22/15 through