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Facet Arthropathy Case Studies

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Review # 258114
Roseblanch Butler
DOI: 7/27/2006. The patient is a 36 -year-old female apprentice engineer who sustained a work-related injury to her neck and back from lifting demolition hall debris.
The patient was subsequently diagnosed with lumbar radiculopathy.

MRI of the lumbar spine without contrast dated 10/16/14 revealed degenerative disc disease and facet arthropathy with retrolisthesis L5-S1, canal stenosis, neural foraminal narrowing.

As per medical report dated 4/8/16, patient complains of having more pain lately. She notes that she had continued to maintain significant improvement to her low back and leg pain as a result of the bilateral L5-S1 transforaminal epidural injection on2/2/15. She also indicates that her low back and leg pain had continued to remain improved by more than 95%. She notes …show more content…

There is also tenderness to palpation bilaterally at paraspinal L5-S1. Straight leg raise is positive bilaterally, localizing to low back pain with ipsilateral leg pain. Sensation decreased over the bilateral L5 dermatomes, left greater than right.
Assessment includes: lumbosacral disc disease with radiculopathy.
Treatment plan includes request for bilateral L5-S1 transforaminal epidural steroid injections continue follow-up as directed. Per procedural report dated 12/16/15, the patient had undergone and had tolerated the bilateral L5-S1 transforaminal epidural steroid injections under fluoroscopic guidance and bilateral L5-S1 epidurograms without complications and was discharged according to protocol.

As per provider 's recommendation, bilateral L5-S1 transforaminal epidural steroid injections would be beneficial for the patient and appropriate as the patient has obtained greater than 50% improvement in pain from the injections, with improvement in functional capacity, and injections are not repeated more than 4 times per year in the body region

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