Physician 1st Quarter 2016 Spine Surgery IRR - Case Study #1
54-year-old male with a prior authorization request for L5-S1 laminectomy (CPT 63030).
FOV/LOV November 5, 2015. The patient has been complaining of low back pain radiating to bilateral legs with numbness and tingling since an injury in June 2014. He has difficulty with tiredness after short walks and has weakness and pain in his right leg.
His physical examination shows 4/5 strength in the right tibialis anterior and extensor hallucis longus with decreased sensation in the right lateral calf. Gait is antalgic. Straight leg test is positive on the right at 35°.
MRI study from September 19, 2014 shows L5 – S1 extruded disk herniation affecting the right S1 nerve root.
He underwent lumbar epidural steroid injection's times two which only provided temporary relief and has participated in therapy over the last three months.
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