Employee Trauma Case Study

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

MRI of the cervical spine obtained on 06/26/13 showed mild degenerative spondylitic changes and status post posterior fusion.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

02/09/16 Progress Report noted that the patient has neck pain, upper back pain, and shooting pain down the arms. The pain is on the left side. It is rated as 3-4/10. It is stabbing, burning, and pins and needles. Medications and rest alleviate the pain. Work, standing, walking, and activity aggravate it. The patient has tried muscle relaxants, strong pain meds, PT, hot packs, and ice, all of which have helped, but he continues to experience substantial pain. The exam revealed that the DTRs were mildly diminished in the left upper extremity.

The patient is an 80-year-old right-handed white female, who presents with her male partner for evaluation of left lower extremity symptoms. She did present for an EMG nerve conduction study in May. At that time, she gave a history of intermittent numbness into the anterior lateral thigh. The numbness rarely extended below the knee at that time, and it rarely occurred on the right. There was no clear radicular component. Her exam was normal. Her EMG of the left lower extremity was limited because she is on Pradaxa, but it was normal and CBs were consistent with a mild motor neuropathy. The diagnosis was possible meralgia paresthetica. The patient now states that the numbness is intermittent. It is on the anterior thigh, but now it goes down into the calf anteriorly and

Williams admitted to Gateway Diagnostics on August 8, 2016. There, he was evaluated by Dr. Skiles. Mr. Williams complained of continued back pain, neck pain and headaches. At Gateway Diagnostic, Mr. Williams was performed a Lumbar Spine MRI, Thoracic Spine MRI, and a Cervical Spine MRI. The Lumbar Spine MIR diagnosed a multilevel degenerative anterior endplate spurring, disk desiccation, disk bulge, facet degeneration and a bilateral neural foraminal stenosis. The Thoracic Spine MRI, diagnosed a discogenic marrow endplate change in the superior portion of the T6 vertebral body, multilevel degenerative anterior endplate spurring in the mid and lower portions of the thoracic spine, uncovertebral hypertrophy, and a disc osteophyte complex effacing the thecal sac nearly contacting the

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

DOI: 7/2/2010. The patient is a 57-year old female claims examiner who sustained a work-related cumulative trauma injury to multiple body parts that include head/cervical spine, shoulders, arms knees, and left hip. As per progress report dated 7/11/16, the patient reports neck and low back pain. IT was noted that the pain is associated with left lower extremity numbness, tingling, and weakness. The patient has tried and failed multiple anti-inflammatories, which causes gastrointestinal upset, except for Celebrex. Her psychiatrist, Dr. Nehoryan has recommended her current regimen including Cymbalta and Restoril intermittently for sleep. It was mentioned that the patient had a fall in early 2/2016 due to left lower extremity numbness and is continuing

DOI: 5/17/2016. Patient is a 52-year old male technician who sustained a work-related injury after hitting his head on a light and losing consciousness. As per OMNI entry, he was initially diagnosed with concussion.

Based on the medical report dated 03/17/16, the patient presents for an upper extremity EMG consultation and reports that the pain has been ongoing since the injury.

Per the medical report dated 12/15/16 by Dr. Vohra, it was noted that a left upper extremity EMG and nerve conduction studies obtained on this date showed normal. Patient is still pending myelogram.

Mark’s main issue related to thoracolumbar back pain with radiation around the right costal margin. As you may be aware, he does have a history of chronic back issues, although this current pain that he has had for a couple of months is new. I note he did have an MRI assessment by a spinal surgeon back in 2007, and underwent and extended period of ?? rehab.