The patient returns today for reevaluation. She reports some improvement in her neck pain, but reports she has been experiencing some significant low back pain as well as pain to her lower extremities. She also reports some continued mid back pain. She denies any new complaints.
1. Persistent posttraumatic cervicalgia.
2. Cervical radiculopathy.
3. Persistent posttraumatic thoracic pain.
4. Persistent posttraumatic lumbago.
5. Lumbar radiculopathy.
The patient and I had another nice talk today. She feels as though prior trigger point injections very helpful to her cervical region for which she requested injections to her lumbar spine region. We discussed the risks and benefits of the procedure verbally and she wishes to proceed. Injections were done to bilateral lumbar paraspinal musculature. A total of six injections were performed. A solution of lidocaine and Marcaine was used. The patient tolerated the procedure well and there were no complications. The patient will continue to follow up with her chiropractic physician and we will continue with physical therapy as well as ice and home exercise. She will call me with any questions or concerns prior to our next visit.