Spurling's Case

DOI: 11/5/1996. Patient is a 60-year-old male parking attendant who sustained a work-related injury to the left upper extremity while trying to open a stuck booth sliding glass door. Per OMNI, he was diagnosed with chronic lumbar strain, right knee degenerative changes, status post shoulder surgery for small tear. Per the QME on 12/16/98, patient was deemed at P & S status.

Per the PT note dated 12/16/14, patient has attended 6 sessions for the thoracic region.
Based on the progress report dated 11/08/16, the patient presents for follow-up of chronic mid and lower back pain, rated as 10/10. He is having increasing pain to the upper back/lower neck lately which has been radiating to the right shoulder with associated numbness and tingling.
The pain is made better by lying down and pulling his legs up on pillows.
On examination of the cervical spine, there is tenderness to palpation to the right lower cervical paraspinal muscles and right trapezius. There is decreased active range of motion of the cervical spine in extension and right rotation. Spurling’s test is positive on the right. Sensation is decreased to light touch of the right trapezius and right lateral shoulder.
At rest, the patient stands with a stooped posture, forward flexed at the waist with flexion in the upper thoracic region.
Assessments include chronic cervical thoracic strain and right cervical radiculopathy.
Recommendation was made for further workup with an MRI of the cervical spine given the changes in the patient’s neurologic status, which are now suggestive of right cervical radiculopathy.
Current request is for 1 MRI of the Cervical Spine between 11/28/2016 and