4th Qtr 2016 Physician MSK (Spine) Case Study#3
54yom- L3-4 laminectomy and discectomy (63047)
Blue Shield California Commercial
C/O with severe radiating pain in left lower limb that travels to the medial aspect of his left knee. He reports falling from a ladder approximately 1 week ago and has been taking Medrol dose pack as prescribed by ER physician.
No bowel nor bladder dysfunction is described. He reports that he has noted over the past few years occasional shooting pain in his legs but never to this severity.
PE: Physical exam is limited due to severe guarding on ROM and strength testing of all left lower limb myotomes, but no asymmetry of muscle testing is noted. Femoral stretch test is positive on the left.Sensation is grossly intact to light touch and there are no asymmetrical reflex changes. Lumbar spine x-ray taken in ER reveals facet arthropathy which is multilevel in nature without evidence of fracture or instability.
MRI reveals an L3-4 disc protrusion with left L3 nerve root compression. Spinal cord is without signal changes.
Surgeon requests Lumbar Laminectomy L3-4
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