Physician 1st Quarter 2016 Interventional Pain IRR - Case Study #2
68-year-old female with 7 months of 5–10/10 low back pain that limits activities. Her pain increases with walking and climbing stairs and decreases with sitting. She has diabetes and hypertension and had surgery for ischemic colitis 12/8/15. She had work-up previously which showed an L1 compression fracture.
Her physical examination showed increased pain in flexion and palpation at L1, no weakness or numbness in the lower extremities and reflexes were brisk but equal. Straight leg raise was negative. MRI of the lumbar spine on 1/7/16 showed 50% L1 compression with retropulsion, small protrusion L3–4, moderate bilateral foraminal stenosis L5–S1 from disc space narrowing. The provider requests bilateral L5–S1 transforaminal epidural steroid injection.
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