The patient presents today for a follow-up appointment. He continues to have chronic neck and lower back pain and pain in the neck down the upper extremity with numbness and tingling. He had previously a left C6-C7 transforaminal epidural steroid injection. He continues to have chronic lower back pain as well with previous back surgery. He has numbness and tingling down both legs from the back surgery. The pain medications are helping the pain at more tolerable level. He denies any memory impairment, oversedation, constipation, nausea, itching, high or buzz with the medications. He is alert and functional with better quality of life since going to the Center. He rates the pain level as 5-6/10 on the visual analog scale with medications and 8 without the medications. No change in his past medical history, past surgical history, family history, social history, allergies, medications, or review of systems.
Cervical spinal stenosis.
We will continue the Percocet 10/325 one to two tablets p.r.n. for pain and Ambien 10 mg at night as needed for insomnia. He is fairly ambulatory at this point and only uses it as needed. I did dispense the Percocet #90 with no refills. Discussed with him the P-Stim procedure. I explained to him the risks, benefits, and alternative treatment options. We will schedule this at his next follow-up as he will prefer to wait until late February 2012 to the procedure. If he has any problems in the interim, he is to contact the office.