4th Qtr 2016 Physician MSK (Spine) Case Study#2
61yom lumbar discectomy (63030)
Blue Shield California Commercial
C/O lower back pain with right lower extremity radiculopathy. For the last 5 months, he has had pain radiating to his right lateral leg and foot, which has prevented him from performing ADLs.
TX: He has failed conservative care including formal PT, medications and epidural steroid injections over the last 3 months.
Past medical history is relatively unremarkable.
PE: reveals 4/5 weakness of right EHL and ankle dorsiflexors with symmetric DTRs and a positive SLR on the right, with antalgic gait.
MRI shows a large HNP at L4-5 on the right side with nerve impingement.
Surgeon is requesting an L4-5 Right discectomy.
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