Qtr 1 Physician RBM 2017 (Spine) case study # 9
CIGNA SI-PPO/OAP Commercial
72158-MRI Lumbar Spine, (spinal canal and contents), without and with contrast
43 y/o F
Case initiated 01/17/2017
The patient was initially evaluated on 1/13/2017 for low back pain and left lower extremity radiculopathy “for evaluation of spinal canal stenosis."
She has a history of L5-S1 Lumbar Fusion in 1992 and last July had a “flare up” of symptoms which resulted in a CT scan which revealed “no significant stenosis." Her pain subsequently improved on oral medications.
Last week the patient had another “flare up” after riding on a boat and developed severe back pain and sciatica with numbness of the leg. She subsequently went to the Emergency Room and was treated with medications which were ineffective. She has had change in bowel function, where she reported loss of bowel control 2 days ago and has been limping and reports her pain as 10/10.
Pertinent physical examination revealed paraspinal and lumber tenderness with muscle spasm and limited ROM. Pertinent motor testing revealed grading of the left knee extensors and plantar flexors @ 3/5 and sensation to be absent in the left L3 dermatome with some hyperactive reflexes. Straight leg testing was positive on the left.
Lumbar spine X-rays showed degenerative changes with good alignment and fusion intact.
The plan was to obtain an MRI Lumbar Spine with IV contrast to evaluate for spinal stenosis due to concerns of severe back pain and radiculopathy with probable Left L4 HNP.
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