Patient Case Study: Lumbar Spine

DOI: 2/5/2003. Patient is a 71-year-old female teacher who injured her back when she fell after trying to avoid stepping on a student. Patient was seen and diagnosed with disc degeneration of the lumbar spine, facet arthropathy status post blocks in the past which gave good relief. MRI of the lumbar spine dated 2/25/05 revealed no significant change compared with the study of 1/30/04. There is spondylolisthesis and spondylosis at L4-5 with facet degenerative changes and mild bilateral foraminal narrowing. There is degenerative disc disease at multiple levels, particularly at T12-L1 and L1-L2, but no stenosis. Mild left-sided foraminal narrowing at L1-L2 and L3-L4 was noted. The patient underwent L2-3, L3-4, L4-5, L5-S1 bilateral facet joint
Per medical report dated 5/28/13, the patient is 90% improved after the injection. She is doing some physical therapy. She occasionally takes Vicodin. She has a lot of discomfort in the lumbar spine, but overall has drastically improved since the injection. Per medical report dated 2/29/16, the patient had relief with the injections in the past. She had over 80% relief with the shots. They are definitely over six months at a time. She has been able to work without restriction with the shots, but as the shots are delayed the pain gets worse. Then her life ends up being off, decreasing her functionality and her needing increasing narcotics is an issue. The patient will be given some pain medication since the shots have been denied, but they would want to have her wean herself off the pain
She is going up on narcotics since the shot has been denied. The patient will be given her pain medication in the meantime. Hopefully, the shot will get approved so she can wean herself off the narcotics and stabilize her spine sooner rather than later. Authorization is requested for a bilateral lumbar epidural steroid injection at L4-5 followed by physical therapy twice a week for four weeks to the lumbar spine. Medications prescribed to include Flexeril 10 mg #90 and Celebrex 200 mg #30. As per worker’s compensation follow up dated 4/18/16, the patient did well with the injection. It gave the patient great relief. Of note, X-rays (no official report) shows that the patient has a little pelvis kyphosis loss of lordosis, 21 degrees of scoliosis but good and a spondylolisthesis at L4-5 as well. She had a little flare-up of pain during a work up. The patient has 23 degree scoliosis, but I really think she would benefit doing stabilization. Physical examination revealed that the spinal examination shows pain with extension and rotation, 1 + pulses, 5/5 motor examination. Positive straight leg raising, cram and