Medical Case Study: Foraminal Injury

DOI: 10/27/2014. Patient is a 48-year old male steamfitter who sustained injury while he was moving equipment when he fell on his back. Per OMNI, he was initially diagnosed with neck, low back, and right shoulder pain.
Based on medical report dated 06/05/15, it was noted that the patient was last seen on 03/20/15 for trigger point Injection. The patient stated that at that time there was minimal improvement and has decided that he would not like to have the second series. He is however, doing physical therapy from which he finds some improvement and is requesting a script today for acupuncture which he had tried in the past and has had very positive results. He takes Mobic 15 mg and Flexeril 10 mg as needed for his symptoms. The patient states that he does feel some improvement.
As of this report, the patient had CT scans of both cervical and lumbar spine which showed at C3-4 there is broad-based central disc herniation with anterior thecal sac impingement.
There is right-sided uncinate joint hypertrophy and right lateral recess stenosis and right foraminal impingement. At C5-6, there is a central disc herniation with anterior thecal sac impingement. There is no foraminal impingement. Well-corticated loose body is seen posterior to the spinous process of T1 likely related to old trauma. The lumbar scan showed at L4-5, there is a broad based disc herniation with severe lateral recess stenosis bilaterally. There is also bilateral foraminal and anterior thecal sac impingement present. At L3-4, there is a disc bulge with anterior thecal sac impingement. There is a left foraminal herniation and left lateral recess stenosis and left foraminal impingement. At L5-S1, there is a disc bulge and there is left foraminal herniation. There is anterior thecal sac impingement with impingement upon the S1 root, There is also left lateral recess stenosis and left foraminal
Impingement.
On examination of the neck, range of motion is restricted with lateral rotation to the right and left to 45 degrees, the left is fairly adequate. There is also tenderness along the cervical paraspinal muscles more so on the right along the trapezius with tender points.
On examination of lower back, there is spasm over the bilateral lumbar paraspinals with some guarding at the lumbar and/or sacral level predominantly over the left side when compared to the right. Flexion is limited.
Impression includes cervical muscle spasm, discogenic neck and lower back pain, cervical radlculopathy, and lumbar radiculopathy secondary to disc herniation.
Plan includes acupuncture, medications Mobic and Flexeril, and continuation with physical therapy. At this time the patient will forgo trigger point injection.