DOI: 03/04/2015. The patient is a 54-year-old male employee who sustained injury when he twisted his right mid and low back after he fell on snow. Per OMNI, the patient is diagnosed with back strain.
MRI of the lumbar spine dated 12/08/15 shows multilevel degenerative disc and facet joint changes and post-operative changes status-post posterior interbody fusion at LS-S1 with mild disc bulge causing moderate to severe bilateral neural foraminal narrowing and mass effect on the bilateral exiting LS nerve roots, epidural fibrosis cannot be excluded without contrast. There is a diffuse disc bulge and facet arthropathy with ligamentum flavum hypertrophy at L4-L5 causing moderate central canal stenosis and moderate to severe bilateral neural foraminal narrowing. There is also left foraminal disc protrusion at L2-L3 causing left neural foraminal narrowing with impingement of the exiting, left L2 nerve root.…show more content… He has a history of lumbar fusion in 2013. After his surgery, his low back pain has gone but has returned. He also noted limited lumbar range of motion, walking and standing with pain. Conservative treatment did not help. Examination of the lumbar spine reveals 40% decreased in range of motion. There is tenderness on palpation of bilateral L4-5 and L5-S1. Extension, lateral bending and rotation cause more pain. Decreased sensation is noted on the right foot. The patient is diagnosed with low back pain, right lumbar radiculopathy and L2-S1 lumbar
