Traumatic Brain Injury Case Studies

The patient is a 43-year-old female who sustained an injury on 08/01/16. The patient was instructed to attach a large 60-pound filter tank with a pump onto the hitch of the truck. As the patient was unloading the tank, the patient lost her grip on the top edge of the tank, which weighed greater than a 100 pounds. As a result, it struck the top of her head, which made her unconscious. She also complained of excruciating pain in the back, bilateral shoulders, right hand, neck, and head.

The patient was diagnosed with a traumatic brain injury with residual balance issues and vertigo, memory and cognitive issues, posttraumatic migraine headaches, posttraumatic aggravation of cervical spondylosis, right wrist internal derangement, and coccydynia.
Treatments rendered to date included medications. The current medications included Norco three to four daily, Ibuprofen, Tylenol, and Prozac.

An MRI of the cervical spine reviewed on 07/19/17 documented chronic loss of vertebral height with associated endplate concavity at C4 vertebrae.
There was a disc desiccation C2-C3 through C6-C7 with disc height loss at C6-C7. There was Modic type II endplate degenerative changes at C4 and C6. At C3-C4, there was a disc bulge of 1.7 mm with narrowing of the right neural foramen and deformity or the right C4 exiting nerve root. At C4-5, there was grade 1 anterior spondylolisthesis with superimposed broad-based disc protrusion abutting the thecal sac but without spinal canal stenosis. There were disc material and degenerative joint change which caused narrowing of the right greater than left neural foramen with deviation of the C5 exiting nerve root with disc measurement of 2.1 mm. At C5-C6, there was a broad-based disc protrusion abutting the thecal sac but without significant spinal canal stenosis. There were disc material and degenerative joint uncovertebral change that has caused narrowing of the right greater than left neural foramen with deviation of the right C6 exiting nerve root and the disc measurement of 2.1 mm. At C6-C7, there was a broad-based disc protrusion abutting the thecal sac but without a significant spinal canal stenosis. There was concurrent bilateral uncovertebral joint degenerative change. The disc material and degenerative joint change have caused narrowing of the right greater than left neural foramen. The disc protrusion measured 3 mm. There was a reversal of the normal cervical lordosis. An MRI of the thoracic spine reviewed on 07/19/17 documented a degenerative loss of disc height at T6-T7 and T10-T11. There were hemangiomas at T1, T4, and T8. There was a straightening or the normal thoracic kyphotic curvature. An MRI of the left shoulder reviewed on 07/19/17 documented a mild supraspinatus and infraspinatus tendinosis with flat downsloping acromion and mild acromioclavicular joint arthritis. The x-rays of the lumbar spine reviewed on
07/19/17 documented a mild rotatory dextroscoliosis with mild L4 and L5 disc space narrowing. The x-rays of the cervical spine reviewed on 07/19/17 documented a reversal of the normal cervical lordosis, a grade 1 C4 on C5 anterolisthesis, and a multilevel disc space narrowing. The x-rays of the shoulder reviewed on 07/19/17 documented a left greater than right acromioclavicular joint narrowing, otherwise unremarkable. The x-rays of the right hand and wrist reviewed on 07/19/17 documented a slight right ulnar negative variance. There were no fractures and significant degenerative changes noted.