The patient is a very healthy 59-year-old male who was the restrained driver of a vehicle involved in a motor vehicle accident on April 30, 2013. He presents today for further evaluation and treatment of his injuries. Specifically, he reports pain to his neck, low back, and left knee. He reports some radiation of pain to the right shoulder and down his right upper extremities. He does report occasional numbness to the right hand. He denies any weakness. He reports low back pain, but denies any pain, weakness, or numbness shooting to his legs although he does have left knee pain from this injury as well. The patient has had MRI scans of his neck and lumbar spine. MRI of the cervical spine revealed a large left paracentral disc herniation at C6-C7 with spinal stenosis and severe bilateral foraminal stenosis, left greater than right and also noted multilevel disc bulging at C3-C4, C4-C5 and C6-C7 as well as foraminal stenosis at C6-C7. MRI of the lumbar spine revealed a large right paracentral disc herniation/extrusion at L5-S1 with central canal stenosis and encroachment upon both descending S1 nerve roots as well as right foraminal stenosis. The patient has been receiving chiropractic as well physical therapy with positive results. He has had muscle relaxants and pain medications prescribed previously. The patient denies any prior history of similar symptoms in the past. A broad-based disc herniation was also noted at L4-L5 with thecal sac indentation.
1. Cervical herniated disc.
2. Cervical radiculopathy.
4. Multiple lumbar herniated discs.
5. Possible lumbar radiculopathy.
7. Left knee pain; etiology to be determined.
The patient and I did have a nice talk today regarding his pain and overall plan of care. His pain has persisted despite his accident being several months ago. He has a positive result from therapy and his chiropractic physician and I recommended that he continue with both of these.
The patient does have significant radicular symptoms although failed nonspecific, and does have significant abnormalities as mentioned on his cervical and lumbar MRI scans. He has significant radicular symptoms to the right upper extremity although the MRI scan shows herniation to the left greater than right. For this reason, electrodiagnostic testing would help us to better pinpoint the causes of his pain. Electrodiagnostic testing of the lower extremities and lumbar paraspinal musculature would also be of help as he does have significant herniations and does have physical exam abnormalities most specifically sensory deficits.
The patient does remain in significant pain and therefore we discussed other treatment options. Specifically, we discussed trigger point injections and we will ask for approval from his insurance carrier before proceeding. I would also like the patient to have an MRI scan of his left knee as he continues to have persistent pain to this region.
In the meantime, the patient will use ice 20 minutes at least twice daily and we did discuss gentle home exercise. He will call me with any questions or concerns prior to our next visit.