The patient is a 76-year-old gentleman that was patient in this office in 2009. He was treated at that time for neck and low back pain. He was doing very well until approximately seven to eight months ago when he started to experience severe low back pain. He claims that this pain has been getting worse over time. It is aggravated when he walks. Because he lives farther from this office, he decided to see a pain practitioner who did two epidural steroid injections on him with no relief of the pain. Then, he decided to return to the wellness Center and was started on chiropractic manipulation with Dr.. He has been doing the conservative management with the manipulation for several months already and is not getting any better. He decided to see the physician at this time to explore any other possibilities in terms of his treatment. He describes his back pain as follows: Duration: Constant. Quality and intensity: 10/10. Radiation: The pain started in buttock area and radiated down both lower extremities. Aggravating factors: Walking aggravates the pain. He cannot walk more than two-thirds of a block before his legs start feeling heavy, numb, and painful. He needs to stop. At the supermarket, he needs to walk leaning against the shopping cart. Alleviating factors: Sitting down and stop walking. Description of the pain: Tingling, numbness, stabbing.
1. Neurogenic claudication.
2. Chronic low back pain.
3. Spinal stenosis.
1. The patient will bring the MRI for evaluation and discussion of treatment. I discussed with the patient the possible treatment options of the spinal stenosis that causes neurogenic claudication. He already tried the conservative approach with therapy, exercises, chiropractic manipulation, and epidural steroid injections. His next option will be the performance of the surgery versus minimal invasive lumbar decompression. I discussed with him the risk, benefit and alternative and technical aspect of the performance of the minimally invasive lumbar decompression. Once he brings the MRI and we are able to review it, I can tell him whether this procedure will help him or not.
2. Recommend continuation of chiropractic manipulation.
3. Weight loss. The patient is obese.
4. Follow-up in one week.