CT Scan Lumbar Case Studies

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend

On 1/16/17 I met Mr. Anderson at the office of Dr. Rampersaud. Mr. Anderson drove to the appointment. He uses 2 canes to walk. He reports that he and his wife drove to Florida on 1/4/17 to 1/15/17. He said they walked everyday while he was there. He reports his pain is a 9. The pain is in the left Si and caudal along with the low back. Mr. Anderson is scheduled for several injections today after we meet with Dr. Rampersaud. Mr. Anderson’s current medications were discussed. I remind Dr. Rampersaud that we are on a tapering process with the medications. Mr. Anderson was instructed to decrease the Dilaudid to 3 times per day from 4; the

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

As per medical report dated 4/19/16, a lumbar MRI with and without contrast was requested to evaluate for a discogenic and/or facetogenic etiology for pain. MRI would also allow evaluation of conditions such as spinal stenosis.

Based on the medical report dated 01/20/16, the patient reports that his low back pain is rated as 9/10 into the right lower extremity. It’s experienced between 76% and all of the time he is awake. Some of the patient’s daily activities are being prevented by this symptom. He reports numbness and tingling in his right lower extremity.

S: Aerotek TM is in HMMA Medical Clinic to follow up with Low Back strain with lumbar radicular pain that radiates down to back of his RIGHT HEEL. According to TM the incident occurred on 6/14/17. TM’s initial radicular pain was down to his left leg but now it is down to his right leg. According to TM for the past 6 weeks he hasn’t done nothing but raying around the house, and his back is not getting batter.

MRI of the lumbar spine dated 12/11/15 reveals disc desiccation with associated loss of disc height at L5-S1; posterior annular tear at L5-S1; hemangioma at L5; and L5-S1 focal right paracentral disc herniation which abuts the thecal sac. Disc measurement is 3.3 mm.

Per medical report dated 09/01/2015, the patient presents low back and right hip pain. She rates the pain as 8/10 and characterized as sharp and stabbing. The pain radiates to the right hip, right thigh, knee, leg, calf, right ankle, and foot and is described to be severe and constant. Her condition is associated with joint stiffness, tingling and weakness. Additionally, the pain is aggravated by any activity or movement, doing excessive work, and prolonged sitting. Relieving factors include application

Review of diagnostic studies and medical-legal reports is included in the physician’s notes. Objective findings note that the patient is mildly obese and appears to be in moderate pain. He does not show signs of intoxication or withdrawal. His gait is antalgic gait and is assisted by cane. Lumbar range of motion is restricted with 50 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral bending, and 10 degrees of left lateral bending. All range of motion is limited by pain. There is tenderness noted in the bilateral paravertebral muscles. Lumbar facet loading is positive on the left side. Ankle jerk is ¼ on the right and 2/4 on the left. Patellar jerk is ¼ on the right side and 2/4 on the left side. There is tenderness noted over the trochanter and pain to the lateral hip with range of motion. Right side motor strength of ankle dorsi flexor is 4/5 and ankle plantar flexor is 4/5. Hip flexor is 5-/5. Light touch sensation is decreased over the lateral calf on the left. Patient has resting tremor of the left lower extremity. His medications are Prilosec 20mg, Celebrex 200mg, Neurontin 800mg, Flexeril 10mg, Duragesic 75mcg/hour patch, Viagra 100mg, Nuvigil 150mg, and Silenor 6mg, Evzio 0.4 mg, and Norco

This is a 48-year-old male with a 6/7/1995 date of injury. A specific mechanism of injury has not been described.

Regarding MRI Lumbar spine, CA MTUS supports imaging of the lumbar spine in patients with red flag diagnoses where plain film radiographs are negative; unequivocal objective findings that identify specific nerve compromise on the neurologic examination, failure to

G. J. is a 28 year-old male patient with no past medical history. On September 13, 2015, he was admitted at Kendall Regional Medical Center with a chief complaint of worsening back pain lasting for over a month. He denies any recent trauma or falls, numbness, tingling, or paresthesia. No urinary symptoms or fever. The patient has been trying multiple medical management options in the outpatient setting, but they have all failed to relieve the pain. G. J. was sent to the hospital for consideration of surgical management given that patient’s medical management was unsuccessful. Patient is admitted to internal medicine for further evaluation and investigation. With the analysis of several MRIs, the patient is diagnosed with

The patient was subsequently diagnosed with unspecified enthesopathy, lower limb, excluding foot; and other intervertebral disc displacement, lumbar region. As per office note dated 4/14/2016, patient complains of right hip pain radiating to right groin and low back pain. Urine toxicology was performed in the office with pending results. As per appeal letter dated 5/7/2016, the patient experienced heartburn. As per visit note dated 5/12/16, the patient complains of right hip pain radiating to right groin and low back pain. The pain is constant, and moderate in intensity associated with weakness in the right leg. He rates pain as 7-8/10 on visual analog scale and reports medications provides fair relief. In addition, he complains of increased anxiety and multiple nocturnal awakenings secondary to lack of progress. He continues to ambulate with assistive device. The patient ambulates with cane favoring his left lower extremities. Examination of the lumbar spine reveals range of motion to forward flexion of 50 degrees, extension of 15 degrees and side bending of 20 degrees bilaterally. There is tenderness

Imaging of musculoskeletal disorders began in the early 1900’s with the invention and utilization of radiography and fluoroscopic equipment (McKinnis, 2014). Evolutions in imaging now allow for clearer digital recorded images of fluoroscopy, radiographs, computed tomography (CT), and magnetic resonance imaging (McKinnis, 2014). From the beginning, imaging has not been an isolated or sole diagnostic tool. The clinician’s expertise in the evaluation process, the comprehensive evaluation and assessment of the patient, documented and reported patient history, associated signs and symptoms, and the additional medical test results along with red flags must be taken into account when considering referral for imaging (Dutton, 2012; McKinnis, 2014). There are several clinical prediction rules and guidelines, which have been created to assist health care providers in managing the utilization and prevention of inappropriate imaging (Dutton, 2012; Gan, Harkey, Hemingway, Hughes, & Duszak, 2016; Gidwani et al., 2016; McKinnis, 2014). Based on the aforementioned information, not all spinal patients will require or should receive spinal imaging.