L4-5: A Medical Case Report
DOI: 8/3/2011. The patient is a 43-year-old male endoscopy technician who sustained a work-related injury to his back while arising from a forward bent position after assisting a patient from wheelchair.
According to the panel QME report on 12/30/13, there should be provision for future medical care including anti-inflammatory medication, short courses of physical therapy for flares, physician visits, diagnostic studies, pain medications and injections. The probability of requiring future surgery is low.
MRI of the lumbar spine on 8/23/14 shows mild degeneration and minimal bulging of the L4-5 disc, asymmetric central disc herniation at L5-S1 affecting the right S1 nerve root, and moderate bilateral L5-S1 neural foraminal narrowing.
The patient underwent bilateral L4-5 and L5-S1 transforaminal epidural steroid injections per procedure reports dated 9/15/15 and 2/16/16. …show more content…
Based on the progress report dated 07/19/16, the patient complains of 8/10 lower back pain, described as sharp, achy and agonizing. Pain is worsened by prolonged standing, walking, bending, twisting, and lifting; and relieved by rest, lying down, medication, heat, acupuncture and chiropractic. He also reports bilateral leg pain, described as electrical and agonizing. Pain is worsened by prolonged standing, walking, bending, lifting and twisting; and relieved by rest, lying down, medication and
According to the panel QME report on 12/30/13, there should be provision for future medical care including anti-inflammatory medication, short courses of physical therapy for flares, physician visits, diagnostic studies, pain medications and injections. The probability of requiring future surgery is low.
MRI of the lumbar spine on 8/23/14 shows mild degeneration and minimal bulging of the L4-5 disc, asymmetric central disc herniation at L5-S1 affecting the right S1 nerve root, and moderate bilateral L5-S1 neural foraminal narrowing.
The patient underwent bilateral L4-5 and L5-S1 transforaminal epidural steroid injections per procedure reports dated 9/15/15 and 2/16/16. …show more content…
Based on the progress report dated 07/19/16, the patient complains of 8/10 lower back pain, described as sharp, achy and agonizing. Pain is worsened by prolonged standing, walking, bending, twisting, and lifting; and relieved by rest, lying down, medication, heat, acupuncture and chiropractic. He also reports bilateral leg pain, described as electrical and agonizing. Pain is worsened by prolonged standing, walking, bending, lifting and twisting; and relieved by rest, lying down, medication and