Forklift Case Study

DOI: 09/09/2016. Patient is a 36-year-old male material handler/forklift driver who sustained injury when he collided with another forklift. X-ray of the lumbar spine dated 09/09/16 showed decreased disc space involving L5-S1, which might be representing degenerative changes.
Based on the medical report dated 10/14/16, the patient states he is currently not having any improvement. He states he still continues to have lower back pain and right L5 radiculitis ending into the right lateral calf. He states the medications have not really helped him. He is the yet scheduled to have physical therapy in the next 1-2 weeks. Patient continues to rate his pain as an 8/10. On examination, muscle strength exam was +5 and reflexes are ++ 1 at L4 and S1 bilaterally and symmetric. There is hyperesthesia at right L4-5. Straight leg raise and Braggard’s were positive on the right at 40 degrees. Current medications include Flexeril, tramadol, tizanidine and meloxicam. Patient had an MRI of lumbar spine without contrast performed on 10/12/2016 (unofficial), which showed degenerative disc at L5-S1 with broad-based left paracentral disc bulge results in mild spinal and bilateral neural foraminal stenosis. Assessments include lower back pain with right L5 radiculitis and L5-S1 degenerative disc with left paracentral disc bulge resulting in mild spinal in bilateral neural foraminal stenosis He was advised to pursue PT. Plan is for right L5-S1 lumbar transforaminal Epidural Steroid Injection (ESI) x1. He was given a prescription for hydrocodone.
Requested from the provider’s office a copy of the MRI of the lumbar spine; however, no callback/report was received prior to the submission of this request to PA.
Current request is for 1 Lumbar Transforaminal Epidural Steroid Injection for the Right L5-S1 Level between 11/28/2016 and 1/27/2017. This is an appeal to review