The patient is here for follow-up visit for her low back pain. The patient is an 86-year-old female who has chronic low back pain that radiates down off and on to her left leg. The patient has also has a history of left hip bursitis and had a trochanteric bursa injection about six weeks ago, which helped her somewhat. The patient continues to get pain in the back with off and on radicular symptoms down the leg. She had an MRI of the L-spine, which shows anterolisthesis of L1 on L2, anterolisthesis of L3 on L4 and L4 on L5 and diffuse degenerative disc disease of the lumbar spine and bilateral facet ligamentous hypertrophy and bilateral central canal stenosis at L3-L4. Pain level is about 6/10. She is also complaining of some neck pain but that is about between 1 and 2. She denies any bowel or bladder dysfunction. She denies any significant weakness in the arm or legs. Otherwise, there are no other change in medical condition or social status since the last visit.
Myofascial pain syndrome.
I discussed different options with the patient. The patient has responded well to trigger point injections in the past. I will proceed with a trigger point injection in the above-mentioned muscle. Under sterile condition, left lower back was recently prepped with povidone-iodine and a mixture of 1 cc of cortisone and 1 cc of Toradol and 8 cc of 1% lidocaine was injected into the multiple trigger points. The patient tolerated the procedure well and was discharged to home. I also recommended the patient to continue with physical therapy. I will see the patient back in followup in a month.