3rd Qtr Physician 2016 Spine Surg Case Study #1
Health Plan: BSCA
Lumbar decompression and discectomy -CPT 63030
This 60 y/o F patient has had low back pain with bilateral radiculopathy for 15 years which recently exacerbated, however without injury.
She denies any bowel or bladder symptoms and grades the pain as 8/10 and constant.
She has tried rest, medications and activity modification without relief…no dates provided.
Physical examination reveals tenderness over the L-S Spine. Motor strength is noted to show 4/5 weakness in the bilateral gastrocnemius muscles with symmetric reflexes.
Straight leg testing is positive bilaterally at 40 degrees on the left and 30 degrees on the right.
Sensation revealed decreased soft touch and pinprick in bilateral S1 dermatomes.
Gait is slow but steady.
MRI Lumbar Spine dated 7/25/2016 shows very large bilateral disc herniations at L5-S1 with bilateral nerve impingements.
A Surgical plan was discussed to request decompressive laminectomy @ L5-S1 bilaterally.
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