4th Qtr 2016 Physician MSK (IP) Case Study#2
63yof-Cervical Interlaminar Epidural Steroid Injection (62310)
Blue Shield California
Reason for request: initial interlaminar epidural at C 6 – 7.
C/O 6/10 neck pain radiating to right scapula and right elbow with numbness and tingling in both hands. She has right shoulder issues and is seeing an Orthopedist. Conservative care included medications. There is a history of remote C3 - 6 cervical fusion.
PE: tenderness to palpation: paraspinals, right trapezius and splenius capitus, positive Phalen’s bilaterally, negative Spurling’s, motor/sensory/reflexes intact.
CT cervical spine: grade 1 anterolisthesis C6 on C7 and C 7 – T1 and posterior disc bulge at C 6 – 7 without nerve impingement.
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