T2-C6 C7 Case Studies
DOI: 10/08/2013. Patient is a 49-year-old female store manager/supervisor who sustained injury to her shoulders and hands when she fell from a ladder. Per OMNI entry, she is status post cervical fusion at C5-6 and C6-7 on 05/26/15.
MRI of the cervical spine done on 05/15/2014 revealed disc osteophyte disease and C3-C4 through C6-C7. There are varying degrees of spinal canal narrowing and foraminal narrowing. There are also degenerative changes at T2-T3. The patient had C5-C6 interlaminar cervical epidural steroid injection and trigger point injections on 08/12/14 and 09/12/14.
Based on the medical report dated 01/17/17, the patient complains of pain to her neck, arm and shoulder. Patient states that the pain has decreased in intensity over the past few weeks. She notes a continuance of neck and left shoulder pain. She has received a trigger point injections since the surgery. …show more content…
She has failed PT for the neck, left shoulder and arm pain. She states that cervical ESI in the past provided moderate relief, but she has not had a cervical Epidural Steroid Injection (ESI) since her surgery. She notes radicular pain down the left arm to the middle and pinky.
On examination of the cervical spine, there is tenderness noted. Well healed surgical scar is present anteriorly. Range of motion is moderately reduced, with extension to 55 degrees with pain, flexion to 45 degrees with pain, bilateral axial rotation to 70 degrees with pain and lateral bending to 40 degrees bilaterally with pain. There is mild crepitus noted throughout range of motion. Spurling’s is positive on the left.
On examination of the left upper extremity, there is pain with palpation and range of motion over the shoulder joint. There is tenderness over the trapezius, supraspinatus, infraspinatus, hand, thumb and second finger. Trace edema is noted in the wrist and fingers. Phalen’s and Tinel’s signs are positive. Biceps and brachioradialis reflexes are 1+.
Limb weakness is present at the left biceps and left wrists extensors at 4/5.
Review of systems is positive for fatigue, body aches, shortness of breath at night, change in alertness, muscle twitching, tingling, joint/muscle pain, muscle cramps, back pain, stiffness, and difficulty sleeping.
Current medications include Lyrica 75 mg, Medrox 0.0375-20-5% topical adhesive patch, oxycodone-acetaminophen 5-325 mg and tizanidine 4 mg. Since the last visit, pain ranged at 7/10. Over the past week, pain treatments and medicines have provided 50% relief.
Assessments include chronic pain syndrome, cervical radiculitis, cervical disc degeneration of intervertebral disc, cervical facet arthropathy/spondylosis, cervical post laminectomy syndrome, cervicalgia, shoulder osteoarthrosis, carpal tunnel syndrome, rule out choric regional pain syndrome, Type 1 upper limb and shoulder pain.
Plan is for a left stellate ganglion block under fluoroscopy.
Current request is for 1 Left Stellate Ganglion Block under Fluoroscopic Guidance; and 1 Post Procedure Follow Up Visit between 1/30/2017 and
3/31/2017.
MRI of the cervical spine done on 05/15/2014 revealed disc osteophyte disease and C3-C4 through C6-C7. There are varying degrees of spinal canal narrowing and foraminal narrowing. There are also degenerative changes at T2-T3. The patient had C5-C6 interlaminar cervical epidural steroid injection and trigger point injections on 08/12/14 and 09/12/14.
Based on the medical report dated 01/17/17, the patient complains of pain to her neck, arm and shoulder. Patient states that the pain has decreased in intensity over the past few weeks. She notes a continuance of neck and left shoulder pain. She has received a trigger point injections since the surgery. …show more content…
She has failed PT for the neck, left shoulder and arm pain. She states that cervical ESI in the past provided moderate relief, but she has not had a cervical Epidural Steroid Injection (ESI) since her surgery. She notes radicular pain down the left arm to the middle and pinky.
On examination of the cervical spine, there is tenderness noted. Well healed surgical scar is present anteriorly. Range of motion is moderately reduced, with extension to 55 degrees with pain, flexion to 45 degrees with pain, bilateral axial rotation to 70 degrees with pain and lateral bending to 40 degrees bilaterally with pain. There is mild crepitus noted throughout range of motion. Spurling’s is positive on the left.
On examination of the left upper extremity, there is pain with palpation and range of motion over the shoulder joint. There is tenderness over the trapezius, supraspinatus, infraspinatus, hand, thumb and second finger. Trace edema is noted in the wrist and fingers. Phalen’s and Tinel’s signs are positive. Biceps and brachioradialis reflexes are 1+.
Limb weakness is present at the left biceps and left wrists extensors at 4/5.
Review of systems is positive for fatigue, body aches, shortness of breath at night, change in alertness, muscle twitching, tingling, joint/muscle pain, muscle cramps, back pain, stiffness, and difficulty sleeping.
Current medications include Lyrica 75 mg, Medrox 0.0375-20-5% topical adhesive patch, oxycodone-acetaminophen 5-325 mg and tizanidine 4 mg. Since the last visit, pain ranged at 7/10. Over the past week, pain treatments and medicines have provided 50% relief.
Assessments include chronic pain syndrome, cervical radiculitis, cervical disc degeneration of intervertebral disc, cervical facet arthropathy/spondylosis, cervical post laminectomy syndrome, cervicalgia, shoulder osteoarthrosis, carpal tunnel syndrome, rule out choric regional pain syndrome, Type 1 upper limb and shoulder pain.
Plan is for a left stellate ganglion block under fluoroscopy.
Current request is for 1 Left Stellate Ganglion Block under Fluoroscopic Guidance; and 1 Post Procedure Follow Up Visit between 1/30/2017 and
3/31/2017.