Steroid Attack Case Summary

DOI: 3/3/2009. Patient is a 56-year-old female slicer who sustained a work-related injury to her back and left hip when she slipped and fell while walking down the stairs/steps. Patient is status post lumbar epidural steroid injection at L5-S1 per the operative report dated 02/01/10.
As per AME report on 6/21/11, the patient’s future medical care includes access to a physician (neurosurgeon), diagnostic studies, physical therapy modalities or acupuncture, over-the-counter medications, and exercise program. The examiner believes that a microdiscectomy at the L5-S1 level on the left would be reasonable.
According to the supplemental AME report on 1/30/12, the patient has had a trial of therapy including physical therapy, epidural and chiropractic treatments. The examiner agrees with the proposed surgical procedure (spinal fusion).
Electrodiagnostic study dated 5/18/16 revealed evidence of chronic bilateral L5 (or L4) radiculopathy.
MRI of the lumbar spine dated 5/27/16 showed disk desiccation at L5-S1. A 3 mm posterior disk protrusion is noted at this level, which abuts but does not efface the thecal sac. In the lateral recesses, there is abutment of the budding bilateral S1 nerve roots. Small synovial fluid lines the facet joints.
Deckey, the patient complains of low back pain with radiating posterior left leg pain, which tends to follow an S1 dermatomal distribution. She admits to having some new symptoms of right knee and leg pain and weakness. The patient rates her low back pain as a 9/10. The symptoms are worse with prolonged sitting, walking, bending, lifting, and twisting. Her pain is made better with rest and change of positions. She has undergone conservative treatment, which consisted of physical therapy without any relief. The patient also underwent 2 lumbar epidural injections, which helped her