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Back Pain Case Summary

569 Words3 Pages

DOI: 6/25/2013. Patient is a 39-year old male commercial driver who sustained injury while he was parked when he got struck from behind by a tractor trailer. Per OMNI, he suffered injury to his neck, back, shoulders, elbows, and knees. He is out of work since the date of injury. He is status post cervical discectomy with fusion at C4-6 on 3/12/14 and a suboccipital craniotomy and decompression of a C1 lamina due to Chiari malformation on 12/29/14.
Per medical report dated 06/30/15, patient presented for low back pain with left anterior leg pain. He has not tried PT or injections. He does have weakness in the left leg. At times, he is unable to put pressure on the left side. He does have numbness/tingling.
On examination, motor strength in …show more content…

He has ongoing progressive back pain with numbness, pain and weakness in the left leg/foot and occasionally on the thigh. He has done physical therapy, but he would now like a definitive plan. Recommendation was made for a L4-5 decompression and fusion. He will need complete facet resection in order to alleviate that lateral recess stenosis, as well as a likely decompressive laminectomy at L3-4 and L5-S1. In the meantime, he was advised to continue physical therapy and home exercises.
Based on the medical report dated 09/01/15, the patient was recommended to undergo a lumbar surgery. He presented for a medication refill of Norco 10/325 in conjunction with Flexeril and Meloxicam.
On examination, he ambulates in a slightly antalgic fashion into the examination room, favoring his left lower extremity. Motor strength with bilateral hip flexion against resistance is rated as 4+/5, extension and retraction of bilateral lower extremities rated as 4/5 on right and 4-/5 on the left and dorsiflexion/plantar flexion of left lower extremity rated as 4/5 and to the right as 4+/5. Sensation to light touch displays hypoesthesia along the left lower extremity. He was assessed to have a lumbar spondylosis.
Per the IME report dated 07/23/15 by Dr. Kercull, IW was diagnosed with herniated d lumbar disc to the left including the L4 nerve

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