Post-thoracotomy/laminectomy syndrome

The patient was last seen in this office on July 23, 2012. At that time, he was evaluated for complaint of low back and thoracic pain. He does have a complicated medical history. In 2007, he underwent thoracic spine surgery for evacuation of a tumor. The surgery was complicated by development of an epidural hematoma that required emergency surgery. As a consequence of this, he sustained some damage to the spinal cord. In 2008, he underwent a lumbar discectomy. He has a history of low back pain for several years and in 2008, the pain worsened to the point that he decided to go to his spine surgeon and have a discectomy. He was under the care of another pain specialist who was treating his pain with opioids. He never had a trial of epidural steroid injections and at one point they tried to do facet medial nerve block but it was denied by the insurance. Since his last visit here, the medications were changed. He was kept on Duragesic patch 125 mcg every 48 hours. He stated that they tried the patch every 72 hours, but by the third day the effect of the medication was wearing off and it had to be decreased to 48 hours. Pyridium was discontinued but he had been using some medication that he had left. I explained him that we will continue the way it was planned. No Pyridium will be renewed. He was also given MSIR for breakthrough pain which he has been using. I discussed with him today the nature of his pain and treatment protocol that was going to develop for him. He brought MRIs of his cervical and thoracic spine since he has been getting follow-up every six months to monitor the presence of the tumor or epidural hematomas. I discussed with him the cervical and thoracic hematomas. I also discussed with him the need to have a new lumbar MRI to evaluate for fibrosis, scar formation, or herniated disc. In addition to the imaging testing, he will have EMG/nerve conduction studies of the upper and lower extremities to assess for radiculopathy. I explained him that the MRIs will show the anatomy whereas the EMG will show the function of these nerves. Once all this information is gathered, I will meet him again in four weeks and at that time we will decide on the further treatment plan.

DIAGNOSES:
1. Post-thoracotomy/laminectomy syndrome.
2. Cervicalgia.
3. Cervical spinal stenosis.
4. Cervical spondylosis.
5. Cervical radicular pain.
6. Lumbalgia.
7. Lumbar radicular pain.
8. Cervical facet joint syndrome.

RECOMMENDATIONS:
1. Prescription for MSIR 50 mg one tablet p.o. q.8h. p.r.n. was given to the patient (60 tablets).
2. Duragesic patch 100 mcg one patch every 48 hours (15 patches).
3. Duragesic patch 25 mcg one patch q.48h. (15 patches).
4. Lumbar MRI was ordered to assess for fibrosis versus herniated disc of the lumbar spine.
5. Upper and lower extremity EMG/nerve conduction velocities were ordered to assess for the presence of radiculopathy and level of radiculopathy.
6. Follow-up in four weeks for medication refill, reevaluation, and treatment. At that time, we will review the MRIs as well as the EMG studies to the patient and we will determine the risk of the treatment.

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