Lumbar Pain Case Study

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DOI: 06/10/2004. Patient is a female store manager who sustained a work related injury while she was stocking and cashing at a thrift store over a period of time.
Based on progress report dated 08/24/15, the patient was seen for re-assessment of chronic mechanical and myofascial pain in the lumbar region. She has undergone two lumbar surgeries, as well as a left abdominal hernia repair and a revision of the ventral hernia repair.
She reports of increasing lumbar pain, described as aching, burning and stabbing that radiates into the bilateral lower extremities with paresthesias and numbness. Her pain level is an 8/10. The pain is more prominent in the left upper extremity.
She did undergo the bilateral L4-5, L5-S1 facet block which she reports was 75% beneficial in decreasing the deep stiffness aching sensation.
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MRI of the lumbar spine done in 06/27/13 showed L1-2, L2-3, L3-4 and L4-5 posterior facet arthrosis. At L4-5, there is a minor residual disc bulge post surgical changes. At L5-S1, posterior facet arthrosis is noted. A right posterior lateral disc hemiation protrusion which abuts the right ventral lateral thecal sac at the S1 nerve root is demonstrated.
On examination, she walks with an antalgic slow gait, which is walker dependent. There are tenderness and trigger points along the bilateral L3, L4, and L5 and bilateral buttock. Straight leg raise is positive bilaterally. Motor strength of the lower extremities is 4/5 to the left and 4+/5 to the

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