Severe lumbosacral paraspinal spasm

The patient is a pleasant elderly female who is here for initial evaluation for significant pain and muscle spasm in the low back. She is a pleasant elderly female who has this pain which started about one month ago. She was doing some conservative therapy and was feeling a little better. However, since the last one week the pain has become excruciating and she is unable to get out of the bed. Pain goes down the leg. She denies any tingling and numbness in the leg. She denies any trauma or fall. She denies any pudendal numbness. The pain is about 9/10. She just saw her primary care doctor who prescribed her Vicodin and Flexeril, which she has taken.

DIAGNOSIS:
Severe lumbosacral paraspinal spasm.
Myofascial Pain Syndrome
Osteoporosis

RECOMMENDATIONS:
Since the patient has so much pain, I will proceed with trigger point injection in the lumbar paraspinal muscle to help alleviate the pain. Under sterile condition, bilateral lumbar paraspinal area was identified. A mixture of one 40 mg of Depo-Medrol and 10 cc of 1% of lidocaine was injected into the bilateral lumbar paraspinal area without any complication. The patient tolerated the procedure well and was discharged home. I will also start the patient on physical therapy to help with her pain. The patient will continue to follow with medical doctor’s advice. The patient might benefit from another trigger point injection in two to three weeks. If the patient’s pain does not get better, I would recommend getting x-ray of the L-spine.

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