Neer's Case Summary
DOI: 11/17/2011. The patient is a 51-year-old female principal device designer who sustained injuries to her neck, thoracic spine and lumbar spine when she slipped and fell on the floor.
MRI of the cervical spine dated 04/09/12 revealed a C3-4 mild arachnoid space indentation related to the 3mm left paracentral disc bulge, slight disc desiccation noted lateral and neuroforaminal pattern.
Based on the progress report dated 02/11/16, the patient complains of pain in the neck with muscle tightness and limitation of motion with forward flexion causing pulling pain into the neck. She does report pain with rotation. The patient reports the back of her neck is always tired. With sitting at work, she constantly grabs the back of her shoulders and neck pulls in forward while extending the head to give her relief. She feels she is chronically tight and does have slouching of the shoulders. She feels her posture is becoming more bent over. Her occupation requires her to sit at a desk using a microscope for …show more content…
Neer’s test is positive.
Diagnoses are C3-C4 3-mm disc herniation of the cervical spine to the left paracentral disc, left shoulder impingement status post decompression on 01/25/13, chronic myofascial pain cervical spine and cervical facet syndrome.
Treatment plan includes TPI to the bilateral levator scapulae musculature for chronic myofascial pain and trigger point activity, continuation with Flexeril and tramadol, spinal Q dynamic postural garment to be worn 30 minutes to one hour for the first few days and titrating its usage over the next 10 weeks to be able to use up to eight hours a day for postural muscle correction of the upper back bringing to correct head forward carriage and lessen strain on trapezium and levator scapulae musculature to avoid the need for continued use of medication and lessen the need for pain
MRI of the cervical spine dated 04/09/12 revealed a C3-4 mild arachnoid space indentation related to the 3mm left paracentral disc bulge, slight disc desiccation noted lateral and neuroforaminal pattern.
Based on the progress report dated 02/11/16, the patient complains of pain in the neck with muscle tightness and limitation of motion with forward flexion causing pulling pain into the neck. She does report pain with rotation. The patient reports the back of her neck is always tired. With sitting at work, she constantly grabs the back of her shoulders and neck pulls in forward while extending the head to give her relief. She feels she is chronically tight and does have slouching of the shoulders. She feels her posture is becoming more bent over. Her occupation requires her to sit at a desk using a microscope for …show more content…
Neer’s test is positive.
Diagnoses are C3-C4 3-mm disc herniation of the cervical spine to the left paracentral disc, left shoulder impingement status post decompression on 01/25/13, chronic myofascial pain cervical spine and cervical facet syndrome.
Treatment plan includes TPI to the bilateral levator scapulae musculature for chronic myofascial pain and trigger point activity, continuation with Flexeril and tramadol, spinal Q dynamic postural garment to be worn 30 minutes to one hour for the first few days and titrating its usage over the next 10 weeks to be able to use up to eight hours a day for postural muscle correction of the upper back bringing to correct head forward carriage and lessen strain on trapezium and levator scapulae musculature to avoid the need for continued use of medication and lessen the need for pain