T2-C6 C7 Case Studies
DOI: 10/08/2013. Patient is a 49-year-old female store manager/supervisor who sustained injury to her shoulders and hands when she fell from a ladder. Per OMNI entry, she is status post cervical fusion at C5-6 and C6-7 on 05/26/15.
MRI of the cervical spine done on 05/15/2014 revealed disc osteophyte disease and C3-C4 through C6-C7. There are varying degrees of spinal canal narrowing and foraminal narrowing. There are also degenerative changes at T2-T3. The patient had C5-C6 interlaminar cervical epidural steroid injection and trigger point injections on 08/12/14 and 09/12/14.
Based on the medical report dated 01/17/17, the patient complains of pain to her neck, arm and shoulder. Patient states that the pain has decreased in intensity over the past few weeks. She notes a continuance of neck and left shoulder pain. She has received a trigger point injections since the surgery. …show more content…
Review of systems is positive for fatigue, body aches, shortness of breath at night, change in alertness, muscle twitching, tingling, joint/muscle pain, muscle cramps, back pain, stiffness, and difficulty sleeping.
Current medications include Lyrica 75 mg, Medrox 0.0375-20-5% topical adhesive patch, oxycodone-acetaminophen 5-325 mg and tizanidine 4 mg. Since the last visit, pain ranged at 7/10. Over the past week, pain treatments and medicines have provided 50% relief.
Assessments include chronic pain syndrome, cervical radiculitis, cervical disc degeneration of intervertebral disc, cervical facet arthropathy/spondylosis, cervical post laminectomy syndrome, cervicalgia, shoulder osteoarthrosis, carpal tunnel syndrome, rule out choric regional pain syndrome, Type 1 upper limb and shoulder pain.
Plan is for a left stellate ganglion block under fluoroscopy.
Current request is for 1 Left Stellate Ganglion Block under Fluoroscopic Guidance; and 1 Post Procedure Follow Up Visit between 1/30/2017 and
MRI of the cervical spine done on 05/15/2014 revealed disc osteophyte disease and C3-C4 through C6-C7. There are varying degrees of spinal canal narrowing and foraminal narrowing. There are also degenerative changes at T2-T3. The patient had C5-C6 interlaminar cervical epidural steroid injection and trigger point injections on 08/12/14 and 09/12/14.
Based on the medical report dated 01/17/17, the patient complains of pain to her neck, arm and shoulder. Patient states that the pain has decreased in intensity over the past few weeks. She notes a continuance of neck and left shoulder pain. She has received a trigger point injections since the surgery. …show more content…
Review of systems is positive for fatigue, body aches, shortness of breath at night, change in alertness, muscle twitching, tingling, joint/muscle pain, muscle cramps, back pain, stiffness, and difficulty sleeping.
Current medications include Lyrica 75 mg, Medrox 0.0375-20-5% topical adhesive patch, oxycodone-acetaminophen 5-325 mg and tizanidine 4 mg. Since the last visit, pain ranged at 7/10. Over the past week, pain treatments and medicines have provided 50% relief.
Assessments include chronic pain syndrome, cervical radiculitis, cervical disc degeneration of intervertebral disc, cervical facet arthropathy/spondylosis, cervical post laminectomy syndrome, cervicalgia, shoulder osteoarthrosis, carpal tunnel syndrome, rule out choric regional pain syndrome, Type 1 upper limb and shoulder pain.
Plan is for a left stellate ganglion block under fluoroscopy.
Current request is for 1 Left Stellate Ganglion Block under Fluoroscopic Guidance; and 1 Post Procedure Follow Up Visit between 1/30/2017 and