C4-5: A Case Study

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DOI: 6/23/2015. Patient is a 51-year-old female cleaner who sustained injury when she tripped and fell when her foot got caught in a sewer grid. She fell on concrete and landed on her right side.
MRI of the cervical spine dated 08/11/15 showed at C3-4, there is a subligamentous posterior disc herniation on slightly eccentric left greater than right, with left greater than right thecal sac impression. There is peripheral extension of the disc herniation into and narrowing the left neural foramen.
At C4-5, there is a subligamentous disc herniation extending eccentrically into and narrowing the left neural foramen with prominent left lateral extrusion and prominent left foraminal narrowing with left C5 nerve root impingement. The left ventral cord is nearly abutted by the left predominant posterior component to the disc herniation. At C5-6, there is a 1 mm retrolisthesis with a broad posterior disc herniation and radial annular tear having a midline left paramedian predominant component impressing on the ventral and left ventral cord margin resulting in central spinal stenosis. Peripheral extension of the disc herniation into both neural foramen results in bilateral foraminal narrowing. …show more content…
There is no need for further active orthopedic care for the neck, including PT. Patient has had a course of PT, massage therapy, heat treatment and transcutaneous electrical nerve unit (TENS).
Per procedure report dated 10/24/16, patient had a cervical steroid injection at C3-4, C5-6 and C6-7 levels with trigger point

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