DOI: 6/12/2006. Patient is a 56-year-old male skid maker who sustained a work-related injury to his lower back when he bent over to pick up a tubing and felt a pull in his back.
Per the procedure note dated 03/12/15, the patient underwent right L4-5 and L5-S1 facet injections.
EMG/nerve conduction studies dated 06/02/16 demonstrated right S1 radiculopathy.
MRI of the lumbar spine dated 06/06/16 showed degenerative changes in the caudal lumbar spine with chronic disc degeneration and small right L5-S1 intra-foraminal disc herniation. In addition, there is focal L5-S1 epidural lipomatosis.
Based on the medical report dated 11/13/16 by Dr. Zheng, the patient received a lumbar medial branch block at L3 on the last visit, through which improved his back pain for some; however, the he continued to have low back pain and right leg numbness and tingling.
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He presents with continuous low back pain and right leg pain. Pain is radiating from low back to right leg and right foot with numbness and tingling. Patient’s pain is still 7/10. Over the years, the patient has been treated with physical therapy as a treatment with subsequent pain improvement.
On examination of the lumbar spine, it appears straightened with a 30% decrease in range of motion. There is tenderness to palpation bilaterally at L3 through S1 paraspinal muscles facet joint. Extension, lateral bending and rotation causes more pain. Straight leg raise testing is positive bilaterally, more on the right side, at 50 degrees. Sensation is decreased to light touch and pinprick at L5