Lumbar disc herniation

The patient is here for a follow-up visit for her lower back, neck pain and mid back pain. The neck pain is gradually getting worse. She is using a lumbar posture pump and doing home stretching and strengthening program that seems to help her but her pain is variable in the lower back. Some day she has no pain and other days she has an excruciating pain. She continues to have more neck pain and numbness down the right upper extremity. The MRI of the C-spine showed disc herniation at C5-C6 , disc herniation C6-C7, disc herniation C4-C5 right greater than left lateral and right lateral foraminal stenosis at C5-C6. Pain level 4-7/10. She had three lumbar epidural injections done of her lower back with some relief. She denies any other changes in her past medical history, medication history, allergies, or review of systems was done.

Lumbar disc herniation.
Lumbar radiculopathy.
Cervical radiculopathy.

I will do EMG/NCV study of bilateral upper extremities to pinpoint the site of nerve irritation. I will prescribe the patient Percocet 5/325 one tablet three times a day for pain. I will decide the further course of treatment depending on the result of the EMG/NCV.


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