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Pain Management Case Studies

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This is a 35-year-old female with a 1/21/2015 date of injury. He was standing on a ladder and cleaning. She began to tip over and she landed on he rknee. DIAGNOSES: Lumbar spondylosis; Lumbar degenerative disc disease; and Lumbar radiculopathy. 01/14/16 DWC Form RFA for left lumbar ESI L3-L4. 01/11/16 Progress Report by Dr. Farid Kia noted a follow-up visit. The patient reported continued pain in the lower back, radiating to the left thigh with standing and walking. She is still working full-time. She denies any heavy lifting, while working. She stated that the pain is throughout the day, but it decreased when she gets home and rest. Pain assessment revealed the location of pain was low back and left knee. It was described as numbness and …show more content…

She reported continued lower back pain that intermittently radiates to the left lateral leg. Previous treatments include PT for 3 weeks, and she has seen a chiropractor once. She has also tried TENS. The patient has been able to continue working since her injury. She has also use opioids ands NSAIDs for analgesia. Current medications: Cyclobenzaprine HCL 10 mg Oral tabs; Levothyroxine Sodium; and Hydrocodone-Acetaminophen. The exam of the lumbar spine revealed paraspinal tenderness and pain with facet loading and extension. ROM was restricted and painful. SLR was positive bilaterally. Treatment Plan: Start cyclobenzaprine; UDS was ordered; PT to be continued; follow-up with PCP; and continue NSAIDs. 11/11/15 Progress Report by Charles Moran MD indicated that the patient has lower back pain. She complains of pain when she lies on her back for a very long time. Long-term medications: Levothyroxine, Omeprazole and Naproxen. Objectively, the back was diffusely tender over the lumbar spine without palpable spasms. The tone, strength and sensations of lower extremities were normal. There was positive SLR at 10 …show more content…

The examination shows back pain radiating into the left thigh. There wass numbness in the left lateral thigh as well. SLR was positive bilaterally. The examination of the lumbar spine revealed paraspinal tenderness and pain with facet loading. The ROM was restricted and painful. The MRI Report showed neural foraminal stenosis and disc bulge at the requested levels. The patient has failed assertive conservative treatment, including medications, PT, TENS and Chiropractic. CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. In addition, ODG states that no more than two nerve root levels should be injected using transforaminal blocks and no more than one interlaminar level should be injected at one session. The request is for ESI right L5-S1 and the guidelines support transforaminal approach at no more than 2 levels. Considering the trial and failure of the conservative treatment, decreased motor strength, radiating pain into the left thigh and positive MRI report; the medical necessity of Transforaminal epidural steroid injection at the right L3-L4 has been substantiated. Recommend

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