The patient comes in today for a follow-up visit. He continues to have chronic intractable lower back pain with history of failed lower back surgery. He has had L2 through S1 laminectomy for spinal stenosis. He has had severe lower back pain and pain radiating down his both lower extremities with associated numbness and tingling. He also complains of numbness, tingling, and pain in the left upper extremity and fourth and fifth fingers. He is currently taking Vicodin and Neurontin for his symptoms from his family doctor. He previously had epidural injections by Dr. with some temporary relief. He recently had a P-stim procedure and he did not find any change in his symptoms. He states he did not find still any stimulation coming from the device. Patient is on Plavix for history of peripheral vascular disease and had stent placed in both lower extremities for vascular disease. The patient is diabetic as well and also has peripheral neuropathy. He denies any other changes characteristics or nature of his pain. He denies any changes in past medical history, past surgical history, medication history, allergies, family history, social history, or review of systems.
722.83 Failed lower back surgery.
724.02 Lumbar spinal stenosis.
354.4 Cubital tunnel syndrome.
356.9 Peripheral neuropathy.
722.81 Failed neck surgery.
I discussed with the patient about proceeding forward with a bilateral lumbar transforaminal epidural steroid injection for his lower back and radicular pain. We will need medical clearance as he will need to stop his Plavix for seven days prior to the procedure. This is over five years since he has had any interventional procedures and we will recommend trying an injection since the P-stim provided no relief.
I am recommending continue with Vicodin and Neurontin. We will recommend physical therapy three times per week for four weeks. We will get medical clearance for the injection as he will need to stop the Plavix. We will see him back in one-month period of time.