Post Ortho AME Case Summary

DOI: 12/29/2005. The patient is a 35-year-old male carpenter who sustained injury to his lower back after falling from a ladder while nailing some plywood. Per OMNI, he was diagnosed with status post lumbar fusion at L5-S1 on 09/01/09, spondylolisthesis at L5-S1, and L5-S1 spinal fusion on 09/27/12. Patient is status post spinal cord stimulator trial on 01/04/13 with poor response. Per Ortho AME dated 03/28/13 by Dr. Fernandez, the patient has permanent impairment with 26% whole person impairment rating. Future medical care includes occasional doctor visits 6-8x/year with prescription medicines, 12 PT sessions for flare-up, which could be exchanged with acupuncture or chiropractic treatments on a one-on-one basis, 2 epidural injections per year, permanent electrical stimulator, further surgery with
He does have some pain control with the use of the Duragesic patches and Norco. It was noted that the psychological evaluation has helped him cope with pain level. The patient is complaining of a new pain in lower back, that is worse when he sits and it is radiating down the legs. He is wondering if there is anything that can be done. He said he has had injections in the past that seemed to help in 2012. Current medications include Duragesic, Norco, Lexapro, Prilosec, Xanax, and Tegaderm. Of note, last urine drug screen is dated 7/14/16 (no report). Objective findings notes that the patient is in mild distress and arises slowly from a seated position. He has tenderness across the lumbosacral junction. He has pain with flexion and extension. With straight leg raising, he is complaining of symptoms down the posterior thighs and calves bilaterally. IW was diagnosed with status post lumbar fusion at L5-S1 on 9/7/2009, spondylolisthesis at L5-S1, status post cord stimulator trial on 1/4/13 with poor response; and depression/anxiety due to his chronic