Lumbar Spine Case Summary

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Review # 258421 william Rose DOI: 4/24/1991. DOI: 4/24/1991. The patient is a 72-year old male truck driver who sustained injury to his back as a result of driving the truck over a rut on the road. The patient was subsequently diagnosed with lumbar spondylosis, lumbar degenerative disc disease, other specified postprocedural states, and lumbago. Lumbar spine 4 views X-rays, AP, lateral and flexion/extension views dated 4/4/16 demonstrates L4-5 degenerative disc disease. As per medical report dated 4/8/16, patient returns for a follow up visit on his lumbar spine and to further discuss surgical options. He complains of low back pain with prolonged walking. He reports that he walks on his own. He has been going to aquatic exercise classes…show more content…
Patient complains of low back pain with prolonged walking. He reports that he walks on his own. He has been going to aquatic exercise classes and has been taking pain medication. He also returns for a follow up visit on his lumbar spine and to further discuss surgical options. On physical examination of the lumbar spine revealed tenderness to palpation on paraspinous muscles. Range of motion revealed flexion of 90 degrees, extension of 15 degrees; with forward bending the patient can reach mid shins. Straight leg raise is negative at 70 degrees. Per assessment and plan, patient is a status post left approach L2-3 and L3-4 Lateral lumbar interbody fusion on 7/22/14 and have a chronic mechanical low back pain status post multiple lumbar spine surgeries. Currently, patient has solid fusion at 2-3, 3-4, 5-1 and open L4-5 segment. L4-5 is suspected to be a significant pain generator. MRI from 10/2013 has been reviewed and it appears that he may be a candidate for an L4-5 Lateral lumbar interbody fusion. With regards to the surgical options, updated MRI with gadolinium would be needed. Spinal cord stimulator trial has also been discussed as a possible

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