Low Back Raadiculopathy: A Case Study

DOI: 6/9/1990. Patient is a 65-year-old right-handed male general worker who sustained a work-related injury which resulted to herniated disc and low back radiculopathy. As per OMNI notes, the patient injured his bilateral upper extremities, back, and hands. He had a lumbar fusion in November 2008 and a femoral nerve decompression on 12/9/2009. As per medical report dated 2/11/2016, IW presents with severe back pain in the lower back which radiates into the left leg which has been associated with weakness and numbness sensation of the left leg. Treatment plan includes patient will continue taking Norco 10/325 mg, Lyrica 25 mg for nerve pain, Soma 350 mg to treat muscle spasm and Celebrex to treat inflammation cause by the muscle spasm. As per
The patient also presents with pain at the fibular head in the distribution of the left peroneal nerve. Neurological examination revealed that the patient has strength of 4/5 of the left hip flexors. The left dorsiflexors, plantar flexors, and hamstring muscles are 4+/5. There is sensory loss in the anterior thigh and the dorsal aspect of the left foot. The patient uses a wheelchair for transportation; however, the patient can walk a few steps with assistance of a cane. There is positive Tinel sign in the distribution of the left peroneal nerve just below the head of the fibula and moderate muscle spasm in the lumbosacral musculature. Of note, the MRI of the lumbosacral spine dated 3/1/16 demonstrated a fusion at the L5-S1 level. At the L4-5, there was a 2 mm broad-based disc osteophyte complex. The left neural foramen was found to be narrow up to 50% primarily due to a spur and the L5 was found to be transition of vertebrae. The radiologist felt that this patient may have a possible arachnoiditis. CT myleogram of the lumbar spine dated 6/24/16 (no official result) revealed a narrowing of the left neural foramen with possible impingement of the exiting left L4 nerve root at the L4-5