Peroneal neuropathy

The patient is a 60-year-old male who works as a mechanic. He has had back pain since 1985. He manages the pain with chiropractic manipulation, over-the-counter medication, and rest. In 2002, he was involved in a motor vehicle accident, in which he was broad-sided. His back pain became aggravated and he had several epidural steroid injections that failed to relieve his pain. In 2003, he underwent a laminectomy, which helped relieve his pain until four years later. The pain started to bother him again and he underwent a lumbar fusion that helped control the pain. In 2008, he was rear-ended and the back pain became aggravated again. At that point, he did not want to have any more surgery and he was convinced by his orthopedic surgeon to undergo a spinal cord stimulator trial which was successful and subsequently he had implantation of the spinal cord stimulator. The spinal cord stimulator was covering his back pain very well, but he still complained of sensation of numbness that travels from his low back into the right leg lateral aspect. The pain started above the lateral knee and travels down to the lateral aspect of the right foot. He describes the sensation as the numbness mostly. He rates the intensity of the pain as 10/10 and it goes down to 4-5/10 with medication. It is aggravated when he bent over or kneels. Oxycodone and the spinal cord stimulator do help to decrease the pain. What bothers him the most is the numbness. He also complains of pain in his cervical area that he describes as a nagging, aching, sometimes burning, and stabbing. The pain is aggravated when he moves his neck and is worse when he moves the neck to the right. It does not appear to travel down into his arms or up into his thoracic spine. The oxycodone also helps with the pain. He has not had any studies such as EMG, MRI, or CT scan to evaluate the neck pain.

The patient has also been diagnosed with bilateral carpal tunnel syndrome. He has managed his pain with the medication, but had not been considered for surgery. He has not received any kind of injection in the carpal tunnel either. He works as a mechanic and the pain has been interfering with his enjoyment of life as well as activities of daily living and work.

ASSESSMENT:
1. Obesity.
2. Carpal tunnel syndrome, bilateral.
3. Cervicalgia.
4. Possible cervical facet joint syndrome.
5. Failed back syndrome.
6. Peroneal neuropathy.

RECOMMENDATIONS:
1. EMG of the upper extremity to evaluate the carpal tunnel syndrome and possible cervical radiculopathy. Cervical CT to evaluate the facet joint as well as the possibility of herniated disc or foraminal stenosis.
2. We will start the patient on physical therapy to emphasize the muscles of the lower extremity. I discussed with him the fact that the numbness may be permanent and may not improve. In the future, this will cause much of an issue. We can try prolotherapy or Prologel. The patient will follow-up in two weeks to discuss the results of the CT of the cervical spine as well as the EMG.
3. I discussed also the performance of the carpal tunnel injection of steroids versus neural prolotherapy to help him with pain in both wrists.
4. I have discussed with the patient also the performance of cervical facet joint injection in order to help with the cervicalgia.
5. Patient may be a candidate for neuropathy protocol.

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