Bilateral lower extremity pain/paresthesia; highly consistent with peripheral neuropathy

The patient presents today for his first follow-up visit since I initially consulted him back on April 15, 2013. He underwent the MRI of his lumbar spine as I have requested at Open MRI and Diagnostic Imaging April 18, 2013. He comes in today to discuss the MRI results as well as possible treatment options for his peripheral neuropathy.

1. Bilateral lower extremity pain/paresthesia; highly consistent with peripheral neuropathy.
2. Low back pain below the beltline; highly consistent with sacroiliitis.
3. Chronic knee pain secondary to chronic knee issues in the past.
4. Lower extremity weakness; most likely due to deconditioning.
5. Plavix

I spent greater than an hour in direct consultation with patient today. My recommendation at this time is to obtain bilateral lower extremity EMG studies to assess the degree of peripheral neuropathy. His MRI from April 18, 2013 shows only a small central disc protrusion at L4-L5 with minimal disc protrusion at L5-S1 with mild multilevel spondylosis. I was able to look at the images myself and surprisingly his study was not as severe as I would have thought. There is definitely notable fluid in the facet joints at L4-L5 and L5-S1.

In addition to the EMG of his bilateral lower extremities to assess the degree of peripheral neuropathy, I am also going to order him a compounded topical cream. We will see how well he does with that over the next few weeks.

With regards to his low back pain below the beltline; this is highly consistent with sacroiliitis and I would like to start him on physical therapy one to two times a week for the next four weeks. If we do not obtain good results with gains in strength and durability, we will consider fluoroscopically-guided bilateral sacroiliac joint injections and ultimately neuroablation of the joints.

There is nothing really to do for his knees at this point and he had negative Stinchfield test bilaterally and I do not feel that hip joint is contributing to his overall pain. I have recommended that he try to get off of his naproxen if possible and switch to Tylenol less than 3000 mg a day to help with pain. He did state that naproxen does help him urinate less during the evening hours and I am just worried about the side effects of the naproxen on possible vasospasm and lower extremity edema. If he is able to come off the naproxen, it would be in his best interest.

I will see him back in the last week of June for reassessment and to see if we need to be more aggressive with regards to pain control. He is on Plavix and is insulin dependent. So, the use of corticosteroids and aggressive interventional pain procedures may be limited, but will also dependent on risks versus benefits.

He seemed very happy with the visit today. I look forward to work with him.


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