Lumbar Spine Case Summary

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DOI: 1/27/2015. Patient is a 52 year-old female certified nursing assistant who sustained a work-related injury on 1/27/2015 to her back while lowering a resident into a wheelchair. The patient was subsequently diagnosed with lumbar radiculopathy. As per medical report dated 4/27/16, patient follows up for low back pain. She complains that it is severe and says that the pain scale is 10. She has been off on total temporary disable as she could not tolerate regular duty. She has also seen a pain specialist who recommends chiropractic treatments and possibly a trial of another lumbar epidural steroid injection. Objective findings revealed tenderness over the L5-S2 spine. Range of motion is decreased to flexion to …show more content…
The patient complains of a severe low back pain and says that the pain scale is 10. She has been off on total temporary disable as she could not tolerate regular duty. She has also seen a pain specialist who recommends chiropractic treatments and possibly a trial of another lumbar epidural steroid injection. Objective findings revealed tenderness over the L5-S2 spine. Range of motion is decreased to flexion to 70 degrees, extension to 10 degrees, and lateral flexion to 25 degrees bilaterally. She is continuing of radicular pain down the right lower extremity to the tips of her toes. She has some pains on the left side as well, which goes down the posterior aspect of her left thigh to the knee level. Treatment plan includes a request for chiropractic manipulation 2 times a week for 3 weeks, a follow up with the pain specialist, and for authorization for Nortriptyline 10 mg for her radicular pain. Per ODG, Chiropractic Manipulation can be done only when manipulation is specifically recommended by the provider in the plan of care. It is a manual therapy that moves a joint beyond the physiologic range-of-motion but not beyond the anatomic range-of-motion. For low back pain, For low back pain, recommend therapeutic care trial of 6 visits over 2 weeks, with evidence of objective …show more content…
The patient complains of a severe low back pain and says that the pain scale is 10. She has been off on total temporary disable as she could not tolerate regular duty. She has also seen a pain specialist who recommends chiropractic treatments and possibly a trial of another lumbar epidural steroid injection. Objective findings revealed tenderness over the L5-S2 spine. Range of motion is decreased to flexion to 70 degrees, extension to 10 degrees, and lateral flexion to 25 degrees bilaterally. She is continuing of radicular pain down the right lower extremity to the tips of her toes. She has some pains on the left side as well, which goes down the posterior aspect of her left thigh to the knee level. Treatment plan includes a request for chiropractic manipulation 2 times a week for 3 weeks, a follow up with the pain specialist, and for authorization for Nortriptyline 10 mg for her radicular pain. Per ODG, Nortriptyline is a tricyclic type of drug, which are generally considered a first-line agent for neuropathic pain, and also for non-neuropathic pain. Analgesia generally occurs within a few days to a week, whereas antidepressant effect takes longer to occur. This class of medications works for patients with normal mood and as well as for those with depressed mood when used in treatment for
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