Lmbar Pain Case Study
DOI: 07/31/2009. Patient is a 50-year-old male maintenance technician who sustained injury to his back while pushing garage bin into the bin area. The patient was subsequently diagnosed with spinal stenosis, lumbar region, with neurogenic claudication; other intervertebral disc degeneration; and radiculopathy, lumbar region. As per OMNI notes, the patient is diagnosed with history of right L5-S1 tear, low back pain, right quadratus lumborum strain, and paresthesias. He underwent lumbar laminectomy at L5-S1, and L3-L4 and L4-L5 decompression of the nerve root on 2/24/2016. As per progress report dated 6/6/2016, the patient complains of lumbar pain. He states that the symptoms are mild. The pain is aggravated by extended walking. He returns after 3 months postoperative
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followup appointment. Postoperatively, he is persisted with completer relief of bilateral leg pain into the L5 and S1 distributions. He is not taking any pain medication on a regular basis at this time. He is not yet returned to work, but is ready to return to work next week. Objective findings revealed that the patient is able to ambulate across the room and walks on his tiptoes. He demonstrates tandem gait when he walks on his heels. Lumbar range of motion revealed flexion of 9 degrees and extension of 20 degrees. He is also able to laterally bend and laterally rotate.
Of note, the patient AP film shows evidence of lumbar decompression extending from the inferior lamina of L3 to the superior lamina of S1. Reviewed of the neural lateral films shows multilevel lumbar degenerative disc disease with loss of disc height at L5-S1 and retrolisthesis at L4-5. Flexion and extension films showed no new evidence of inability. Diagnosis includes states post L3 through S1 lumbar decompression; low back pain; bilateral lumbar radiculopathy, left equal to right consistent with the L5 and S1 distributions; multilevel lumbar degenerative disc disease; lumbar herniated nucleus pulposus L4-L5; severe lumbar spinal stenosis L4-L5; and moderate-to-severe foraminal stenosis at L5-S1 with impingement of the exiting L5 nerve root. As per treatment plan, it was noted that the patient appears to be doing well after 3 months from surgery. The patient had great relief from his preoperative leg pain and back pain and is ambulatory on a regular basis and doing core exercise on a regular basis. He is not taking any pain medications on a regular basis. At this point, he can return to work next Monday 6/13/16 full duty without
restrictions.
followup appointment. Postoperatively, he is persisted with completer relief of bilateral leg pain into the L5 and S1 distributions. He is not taking any pain medication on a regular basis at this time. He is not yet returned to work, but is ready to return to work next week. Objective findings revealed that the patient is able to ambulate across the room and walks on his tiptoes. He demonstrates tandem gait when he walks on his heels. Lumbar range of motion revealed flexion of 9 degrees and extension of 20 degrees. He is also able to laterally bend and laterally rotate.
Of note, the patient AP film shows evidence of lumbar decompression extending from the inferior lamina of L3 to the superior lamina of S1. Reviewed of the neural lateral films shows multilevel lumbar degenerative disc disease with loss of disc height at L5-S1 and retrolisthesis at L4-5. Flexion and extension films showed no new evidence of inability. Diagnosis includes states post L3 through S1 lumbar decompression; low back pain; bilateral lumbar radiculopathy, left equal to right consistent with the L5 and S1 distributions; multilevel lumbar degenerative disc disease; lumbar herniated nucleus pulposus L4-L5; severe lumbar spinal stenosis L4-L5; and moderate-to-severe foraminal stenosis at L5-S1 with impingement of the exiting L5 nerve root. As per treatment plan, it was noted that the patient appears to be doing well after 3 months from surgery. The patient had great relief from his preoperative leg pain and back pain and is ambulatory on a regular basis and doing core exercise on a regular basis. He is not taking any pain medications on a regular basis. At this point, he can return to work next Monday 6/13/16 full duty without
restrictions.