Pain Management Case Summary

Based on the latest medical report dated 04/08/16, the patient presents for follow-up of his lower back pain. He is status post radiofrequency facet on the left that initially helped with left sided lower back to 60%. He stated that PT was stopped by insurance for the past 2 weeks. Since he started PT, he has been having increased spasm across his lower back with pain into the left lower extremity. IW feels that PT

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

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.

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

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

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

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

DOI: 8/24/2008. Patient is a 55-year-old female manager who sustained injury to her neck and back when she slipped and fell while walking down a set of pull out stairs. Per OMNI, she is diagnosed with cervical strain with radiculopathy and lumbar radiculopathy. She underwent C5-6 partial corpectomy and fusion in 05/31/2011.

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last

On 12/08/2017, the claimant had low back pain with radiation to the bilateral lower extremities. She reported numbness and weakness. It was noted that physical therapy aggravated the symptoms. Objective findings showed tenderness in the lumbar spine with pain at the terminal range of motion.

At today's visit he is accompanied by his wife. He is awake, alert and oriented. He reports that his back pain has improved with the pain regimen he was started on last Friday. He complains of lower back pain that he describes as achy and constant; he rates his pain as a 7/10 in severity. He states that his pain doe not radiate, but it affects his mobility and impedes his ability to get out of bed by himself. His pain regimen is Morphine ER 15 mg p.o every 12 hours and oxycodone/apap 10/325 mg p.o every 4 hours as needed for breakthrough pain. He has taken 6 as needed breakthrough doses daily since Friday. He states that his pain has improved but his goal is to have his pain a little better than 7/10, then he will be able to perform his ADLS

Plan is for right lumbar facet ablation. He last had this done in October 2015. The patient notes he had about 60% relief for 10 to 11 months following that procedure. Patient had over 85% relief of their usual and chronic low back pain for 2 days after the injection. The patient notes that their functional capacity had improved as well, as evidenced as completing activities of daily living more effectively after the procedure. The patient's use of pain medications was also decreased after the procedure. Pain has returned.

Treatment plan includes chiropractic treatment 2x a week for 3 weeks for the lumbar spine flare up post P & S and CMP to evaluate liver dysfunction due to prolonged use of narcotics.