Lumbar Laminectomy Case Summary

HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent low back pain since that time. Last December she started a job where she had to lift boxes that weighed approximately 40 pounds. Around the first of January this year she began to complain of back pain that

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.

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.

Requested verification from the provider’s office on ; however, no callback/report was received prior to the submission of this request to

Is the request for 1 Anterior Cervical Discectomy with Fusion at the C5/6 Level between 9/8/2016 and 11/7/2016 medically necessary?

Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is

01/14/16 Progress Report noted that the patient has severe and constant pain. It is associated with numbness, tenderness, and restricted motion. Current pain level is 8/10. The patient is here for injection to the left subtalar joint. The exam of the left ankle revealed intact skin. There was no erythema or abrasion. No signs of infection. NVI distally. Distal sensation intact and brisk capillary refill. Clinical Assessment: The patient would like to go ahead with the

She did have an EMG nerve conduction study test of the upper extremity which did confirm evidence of chronic left C7 radiculopathy. She takes the hydrocodone 7.5/325 mg sparingly only when pain is intolerable. She also indicates she did experience significant improvement of her pain after she had a left C6-7 transforaminal epidural steroid injection in November 2015. She states she had relief for approximately 2 months. She states she is interested in trying another injection. Her pain is worse with activities using the left upper extremity, improves with rest and medication. She reports her pain level today is

Based on the progress report dated 05/17/16, the patient presents for reevaluation of her right knee pain. It has been about the same though she states that when she gets acupuncture, it does decrease pain for a period of time and allow her to exercise more. She has been walking 45 to 50 minutes twice a day. She uses

Per medical report dated 10/26/15, the patient was provided with a cervical epidural block X 1.

Per PT treatment log dated 11/18/15, the patient has attended 19 PT visits for the thoracic and lumbar spine from 08/27/15 through 11/13/15.

02/09/16 Progress Report noted that the patient’s current medication regimen provides moderate pain relief without any adverse effects. The patient stated that he has seen Dr. Smith for IT pump clearance and would like to proceed with the trial. He has chronic lumbar back pain. The pain radiates the left buttock, left posterior thigh, left lateral thigh, left lower leg, left foot, and right lateral thigh. The patient describes the pain as sharp, dull, aching, bumping, stinging, and throbbing. The onset was sudden immediately after the injury. The symptoms are constant and the episodes occur daily. The symptoms are described as severe and worsening. Back motion, lifting, and bending exacerbate the symptoms. Associated symptoms include leg numbness, foot numbness, leg weakness, and foot weakness. Current treatment includes opioid

Patient is diagnosed with lumbar arthrodesis and bilateral sacroiliac joint dysfunction. She is status post bilateral sacroiliac joint arthrodesis with X-spine instrumentation in 06/08/2015.

As per office notes dated 8/26/16 the patient complains of dull and aching pain of the neck. She rates it as 7 without the medications and at 5/10 with medications. Pain is aggravate with activities and relieved with rest and medications. Neck pain us associated with headaches and radiating pain, tingling, and numbness to bilateral upper extremities. Patient is complaining of having acid reflex ad acute exacerbation of muscle spasm. Lumbar back pain is dull and aching rated at 6 without medications and 4 with medications. Pain is aggravated with activates such as forward back bending, lifting, prolonged sitting, standing, walking, and it is relieved with rest and medications. Lower back pain is associated with radiating pain, tingling, and

Per the medical report dated 05/27/16 by Dr. Joshi, the patient continues toward goals. Patient reports that PT alleviates her pain, improves overall functional limitations, allows her to perform activities of daily living (ADLs) with less difficulty and allows her to take care of infant child without assistance or difficulty.