4th Qtr 2016 Physician MSK (Spine) Case Study#1
47yom Artificial Disc Replacement C5-7 (22856)
Blue Shield California Commercial
C/O severe neck and bilateral shoulder and arm pain for the last 8 months
TX: formal PT, medications and epidural injections over the last 3 months without relief.
PE: Pertinent physical examination revealed slight weakness of bilateral deltoids with decreased biceps jerks bilaterally and no evidence of myelopathy. There is restricted ROM of the cervical spine to F/E and rotation with pain.
MRI reveals C5-6 and C6-7 HNPs with central stenosis with mild facet hypertrophy and early degenerative disc disease.
Surgeon is requesting a 2-level ADR.
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