Iw Case Report

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DOI: 5/22/2000. Patient is a 52-year-old female stitcher operator who sustained injury while she was pushing load onto a stitcher when she strained her right shoulder, wrist elbow, and neck. She underwent exploration of cervical fusion at C5-T7 with anterior cervical discectomy with fusion at C3-C5 on 12/13/11 and implantation of new implantable pulse generator (IPG) and spinal cord stimulator unit on 09/17/14. Based on the latest medical report dated 01/29/16, the IW presents for follow up of neck and shoulder pain. IW complains of increased pain and swelling in her neck, supraclavicular, clavicular and trapezius areas bilaterally, worse on the right. IW states her muscles are tight and tense. IW continues with choking on saliva at times, increased from her normal. IW complains of increased radicular neck pain with pain radiating between her shoulder blades, arms and fingers. IW notes she gets a purplish hue to her hands after driving and when her neck pain increases. IW complains of increased headaches in general all over her head. IW states she continues to use her cervical stimulator 100% of the time unless she is driving. IW also complains of fatigue, double vision/eye pain/blurring, earache/decreased hearing/hoarseness/difficulty…show more content…
IW had a left C2-C3 and C4-C5 TFEI on 7/20/15.Pre/post visual analog scale (VAS) score is 5/10 to 2/10 (50% pain relief). IW had a right C2-3 and C4-5 TFEI on 3/09/15. Pre and post visual analog scale (VAS) score is 7/10 to 3/10 (50% pain relief). Relief lasted 2-3 months for each procedure. With radicular symptoms resolved, household chores made easier. IW complains of pain radiating between shoulder blades into arms and fingers. MD recommended to repeat this injection as patient had previous documented success over recommended interlaminar injections per
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