DOI: 01/31/2006. Patient is a 39-year-old male plumber who sustained a work-related injury to his back and elbow when he slipped and fell while going down the stairs. Per OMNI, he is status post lumbar fusion at L5-S1 on 7/19/10. The patient was declared permanent and stationary as of 8/15/11 with future medical care including physician visits, medications, possible surgery, bone growth stimulator, lumbar brace, and vocational retraining. On 12/18/12, he underwent removal of hardware and inspection of fusion.
Per AME report by Dr. Sommer dated 05/28/14, the patient is P & S since 06/13/13.
Based on the neurosurgical lumbar spine consultation report dated 12/08/15, the patient states his pain is 5-9/10. The pain is 80% back and 20% in the
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The patient used a four poster walker after the spinal surgeries in 2010 and then graduated to a cane after hardware removal in late 2012. He is now taking Norco 5 mg 4 times daily. He has not had any physical therapy in the last two years and does not recall being given home exercise program from physical therapy. He is not doing home exercises. He has not had any epidural steroid injections and chiropractic treatment for the last two years. He does have a TENS unit, which he uses intermittently. As of this report, the first surgery helped him 10%, and the second surgery had no benefit. On examination of the lumbar spine, standing range of motion is 20 degrees. Straight leg raising is 80 degrees on the right, and 90 degrees to the left. There is diminished right heel/toe walking/raising. Patient is only able to do heel-to-toe raising about 0.25 inch off the ground. His gait is broad based. Tandem is not possible. He uses a cane. There is an obvious limp. During examination, he leans to the left to unload the right side and fidgets and changes positions every 5-10 minutes. Hip exam shows positive Patrick’s test and trochanteric percussion on the right. Knee reflexes are 1-2. Ankle reflexes are absent. Motor shows 4/5 weakness, 60-80% of normal, in the right