Work-Related Injury: A Case Study

MRI of the cervical spine dated 08/17/16 showed at C3-4 and C4-5, there is mild posterior disc bulging.

MRI of the lumbar spine dated 07/30/15 demonstrated interval post-surgical change with removal of the disc extrusion at L4-5. There is residual granulation tissue versus broad-based left paracentral disc protrusion with left lateral recess stenosis.

Per the AME report dated 07/08/15, the patient was deemed P & S with regard to her right knee and lumbar spine as of this date. Future medical care includes ongoing exercise program, occasional orthopedic visits, brief periods of PT, anti-inflammatory medications for flares, prescription medications and periodic injections.

MRI of the cervical spine dated 03/09/2016 reveals a multilevel cervical spine degenerative disc changes, most pronounced at C4 to C5, C4 to C5 diffuse disc bulge with central protrusion causing moderate spinal canal narrowing, increased fluid weighted signal in the paravertebral soft tissues posterior to the left C3 to C4 lamina and minimally increased fluid weighed signal in the left C3 to C4 lamina and the right facet joint, C4 to C5 right facet joint bone spur.

MRI scan of the lumbar spine with contrast dated 7/17/2015 showed compression of the descending left L5 nerve root at L5-S1 on the basis of a 6.1mm left paracentral disc extrusion and compression of the descending left L4 nerve root at L3-L4 on the basis of a 6mm left-sided pre-foraminal and foraminal disc extrusion.

Based on the medical report dated 03/30/16, the patient has had pain in the right lower leg, numbness and tingling on the left side as well, rated as 8-9/10.

DOI: 12/13/2012. Patient is a 64-year-old male security officer who sustained a work-related injury to the right knee when he missed a step and fell down the stairs. As per Omni, the patient had a right knee meniscus tear. The patient had right knee replacement on 11/19/14. Per QME Dr. Murphy on 08/11/15, the patient has a 20% whole person impairment rating. Future medical care includes 4-6 visits per year for recurrent symptoms, narcotic/nonsteroidal anti-inflammatory drugs (NSAIDS) in addition to gastrointestinal stabilizing medications, pain management specialist monitoring, office visit with an orthopedic surgeon once a year with X-ray, revision surgery in the future and bone scan.

MRI of the lumbar spine dated 07/02/16 revealed diffuse disc bulging at L3-4, L4-5 and L5-S1. Mild bilateral foraminal stenosis is seen at L3-4 and L4-5.

On examination, there is tenderness on palpation of the lumbosacral area. There is lumbosacral spine pain elicited by motion. Lumbosacral spine motion was normal with mild pain. Sensation to light touch is decreased over the dorsal aspect of the left great toe. Assessments are lumbar sprain and left L4-5 herniated disc. Patient was provided a script to continue with PT.

DOI: 12/18/2015. The patient is a 60-year-old male quality control manager who sustained a work-related injury when he fell from a 6-feet scaffold when he stepped on an unsecured board. Patient underwent open reduction and internal fixation on 1/8/2016.

Per verification to the PT facility, the patient has attended 4 PT sessions to the cervical/thoracic and lumbar spine, right wrist and left knee from 03/26/16 through 06/17/16. It was verified from the provider’s office that this is an initial request for chiropractic treatment.

X-ray of the lumbar spine with 2-3 views obtained on 09/23/16 showed posterior fusion hardware present at L5-S1, laminectomy changes at L5-S1 and adequate appearing alignment.

MRI of the cervical spine obtained on 03/05/15 revealed a posterior disc herniation at C3-4 impressing on the ventral thecal sac and borderline central spinal stenosis. Peripheral disc encroachment toward the foramen is unchanged. A subligamentous posterior disc herniation at C4-5, is impressing on the thecal sac and borderline central spinal stenosis. Peripheral disc encroachment is seen toward the foramen. At C5-6, a subligamentous posterior disc herniation impressing on the ventral thecal sac with peripheral encroachment toward the right neural foramen, borderline central spinal stenosis and right greater than left neural foraminal narrowing findings are unchanged. At C6-7, a left lateral subligamentous disc herniation is demonstrated encroaching into the left neural foramen with mild left foraminal narrowing, which is newly present. A focal midline subligamentous disc herniation at C2-3 again impresses on the thecal sac.

Based on the medical report dated 05/02/16, the patient states that he is experiencing more pain in his left shoulder on this visit than he has in a while. He reports relief with the steroid injection. He continues to attend PT 3 times a week. He states that he feels some improvement with PT.

According to the AME report on 4/30/15, additional medical care may be of value consisting of physician visits, careful use of narcotic analgesics, nonsteroidal anti-inflammatory drugs on a demand or maintenance basis with consideration of addition of a proton pump inhibitor, physical therapy, psychological support, consideration of cortisone injection to the left hip, and an unsupervised home exercise program.