L4-5 Nursing Case Studies

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DOI: 07/17/2013. This is a 25-year-old female cashier who incurred injury to her low back when she missed a step and fell off a ladder while stocking sleeping bags. MRI of the lumbar spine dated 10/03/2013 revealed broad based central disc protrusion at L4-L5; moderate discogenic edema along endplates at L4-5; and broad bulge with a central annual tear at L5-S1. CT scan of the lumbar spine dated 01/08/2014 revealed that at L3, bilateral pars interarticularis defects are seen with sclerotic margins. The vertebrae at L3-4 are normal in present on the prior MRI. The vertebrae at L3-4 are normal in alignment. At L4-3, there is 2 mm of anterolisthesis. Bilateral L4 pars interarticularis defects are seen with sclerotic margins. Office notes dated 06/28/2016…show more content…
As per office notes dated 7/19/16, the patient complains of chronic low back pain at the localized curvature. There is radiating pain, which is increased since the fall. There is limited range of motion. Pain is exacerbated with walking, standing, and sitting. The patient had post lumbar surgery on August 2015. She states that the pain is progressively getting worse. Objective findings revealed pain in the lumbosacral region, more in the sacroiliac joint. Positive findings on fortin finger flexion test. There is limited lumbar flexion. The patient is subsequently diagnosed with lumbar sacral spondylosis; sacroiliac joint arthritis; and low back pain. Treatment plan includes diagnostic bilateral sacroiliac joint injection under ultrasound guidance. Then if the patient received good relief, then she is to proceed with sacroiliac joint radiofrequency ablation. A course of physical therapy would be appropriate since she has not had any physical therapy for increasing range of motion since her surgery 8/4/2015. Plan also includes weaning off opioid

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