Neck Pain Case Studies

DOI: 08/18/2007. Patient is a 53-year-old male registered nurse who sustained a work-related injury to his neck when he tried to pull a patient. Per OMNI, patient is diagnosed with back pain. IW was declared P & S in 2009.

He is status post C5 to C6 fusion in 2005 and C3 to C5 anterior fusion in 2008.
MRI of the cervical spine obtained on 10/29/14 showed postoperative changes from C3-6. At C6-7, there are mild degenerative disc space changes along with a broad- based disc bulge and some posterior ligamentous thickening resulting in mild to moderate canal stenosis without any significant foraminal stenosis or nerve root compression. There is no abnormal spinal cord signal or any true spinal cord compression.
Per office visit note dated 11/20/2015, patient complained of neck pain. His medications are Advil 200mg, Norco 5/325mg, and Flexeril 10mg. He has been treated with cervical interlaminar epidural steroid injection, which helped him immensely with the radicular symptoms. He has failed pain medication, physical therapy, rest, home exercise program, and even surgery.
Based on the progress report dated 07/08/16 by Dr. Kasturi, the patient complains of neck pain and headaches, right sided. Pain is rated as 8/10, described as dull, aching, sharp shooting and burning. Pain primarily radiates in the neck region. Alleviating features include rest and pain medications. Aggravating factors include work, driving, turning head and getting