Lumbar Spine: A Case Summary

DOI: 12/18/2014. The patient is a 56-year old male route sales representative who sustained a work-related injury to his lower back due to slip/fall on black ice while walking from his truck. As per OMNI entry, he was initially diagnosed with lumbosacral sprain.

MRI of the Lumbar Spine without Contrast dated 01/23/2015 showed lumbar spondylosis at L1-2 though L5-S1 discs. At L4-5, there is a 4-mm posterior osteophyte-disc complex more prominent laterally and on the left side. There is moderate to severe narrowing of right and severe narrowing of the left L4-5 neural foramina. At L5-S1, there is a 4-mm posterior osteophyte-disc complex with moderate narrowing of the neural foramina bilaterally.

Per operative report dated 05/20/2015, the patient

He has some numbness and tingling into the posterior aspect of the left thigh and states that after the facet joint injections, he has had about two to three weeks of complete pain relief. He has noticed increased pain in the last couple of weeks with symptoms similar prior to the injection. He has been using ibuprofen and Robaxin with good benefit and states that the pain is usually worse with activity, standing for long periods of time. The patient had previously completed six physical therapy sessions, 12 chiropractic sessions, and 12 acupuncture sessions, but continues to have symptoms down his left

He previously had facet joint injections but only with short term good benefit. He continues to take ibuprofen and Robaxin as needed.

On examination of the lumbar spine there is pain on palpation over the lumbar paraspinals. Range of motion was full. Pain is worse on extension and rotation. Sensation is intact to light touch and pinprick in all dermatomes in the bilateral lower extremities.

Diagnoses are lumbago and facetogenic