Forklift Case Study

DOI: 6/3/2016. Patient is a 50-year-old male forklift operator who sustained injury when he was hit by a forklift. Per OMNI entry, he was initially diagnosed with neck contusion and crushing bruises.

MRI of the lumbar spine obtained on 08/18/16 showed mild retrolisthesis of L5 on S1. Disc desiccation is noted with decreased disc height at L2-L3, L4-L5, and L5-S1 levels. Modic type II endplate degenerative change is seen along the apposing endplates of L5-S1. Schnorl's node is noted at T12.There is a hemangioma at L1 down to L5. At L2-L3 and L3-L4 levels, there are broad-based disc protrusions abutting the thecaI sac, causing narrowing of the bilateral lateral recess and bilateral neural foramen that contact the bilateral L2-3 exiting nerve

Patient continues to have pain that is unresolved with conservative treatment such as physical therapy and medications.

Patient has additional radiculopathy in neck and lower, which radiates into arms and legs with hypoesthesia, which are documented in physical examination.

He also complains of nervousness and anxiety.

On examination of the cervical spine, range of motion shows flexion of 45 degrees, extension of 50 degrees, bilateral bending of 30 degrees, and bilateral rotation of 60 degrees. Positive Spurling and Foramina Compression tests are demonstrated. There is tightness and spasm at the trapezius, sternocleidomastoid and strap muscles, bilaterally.

On examination of the lumbar spine, palpation reveals hypertonic muscle spasm in the paraspinal musculature noted bilaterally. Palpation reveals tenderness of the left and right sacral iliac joint with active trigger points on the left and right gluteus muscles.

Straight leg raise is positive bilaterally at 65 degrees with L4-5 and LS-S1 dermatome distribution. Cross positive Straight leg raise is noted on left at 75 degrees, with pain to the lower back. Sensation to sharp and dull stimulus was intact bilaterally in both

Range of motion was restricted inflexion and extension due to pain.

Patient was diagnosed with impaired vision, cervical spine sprain/strain/herniated cervical discs, lumbar spine sprain/strain/herniated lumbar disc at L4-5 and L5-S1, right shoulder sprain, right elbow sprain and right hand sprain/strain rule out tendonitis and carpal tunnel syndrome.

Treatment plan includes to start chiropractic treatments for 2 x 5 weeks for the cervical and lumbar spine to improve range of motion, improve function and decrease pain and spasms; cervical spine ESI at C5/C6 and C6/C7 and lumbar ESI at L4-5 and L5-S1 to attempt to reduce pain, decrease medication intake and increase functional capabilities.

He was given a refill prescription for topical creams, Norco 10/325 mg 1 tablet every 4-6 hours #90, Ultram extended release 150 mg 1 tablet twice daily #60, Celebrex 200 mg 1 capsule daily #30, Protonix 20 mg 1 capsule twice daily #60 and Fexmid 7.5 mg 1 tablet three times a day #120.

Per verification from the provider’s office, the IW has not had a previous cervical ESI and this is an initial