3rd Qtr Physician 2016 Spine Surg Case Study #4
Health Plan: BSCA
Lumbar Discectomy- CPT 63030
This 65 y/o F patient developed acute onset of left lower extremity radiculopathy in January 2016 without trauma. The pain is constant and is unresponsive to oral medications and 2 months of physical therapy and now affects her ADLs. She ambulates with a limp and cannot find a comfortable position.
Physical examination revealed no lumbar tenderness. Lumbar ROM is limited and flexion reproduces left radicular complaints. Straight leg testing is positive on the left at 30 degrees with 4/5 weakness in the left ankle dorsiflexors.
Imaging included an MRI from March 2016 with an extremely large HNP at L4-5 with disc extrusion to the left causing severe compression of the L5 nerve root.
Surgeon requests L4-5 discectomy.
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