Download Page 1 of 4 Patient Name : WILSON, J.B. Date of Birth : 05/01/68

River North Pain Management Consultants
Axel Vargas, M.D.,
Regional Anesthesiology and Interventional Pain Management.
One East Erie Suite # 300
Chicago, Illinois, 60611
Patient Name
:
WILSON, J.B.
Date of Birth
:
05/01/68
Claim #
:
AF500194WC08-4
Phone: (312) 951-6471
Fax: (312) 649-5747
E-mail: [email protected]
www.rivernorthpmc.com
Date of service : 12/13/08
HISTORY OF PRESENT ILLNESS: Mr. Wilson comes referred by Dr. Ravi Barnabas
for consultation. He is a very pleasant 59-years old gentleman from Chicago, Illinois who
presents with an approximate 4-months history of progressive distal lower back pain and
associated left-sided sciatica pain after a fall he experienced while at work.
Mr. Wilson is a poor historian; nevertheless he informs me that this past 08/25/08, while
at work, as he “scrapped some tile floor” he apparently tripped and fell backwards.
Immediately he experienced a sudden onset of distal lower back pain and left-sided
sciatica symptoms. Nevertheless, he continued to work.
As the pain progressively worsened over the next few days, he went to the John Stroger
Hospital emergency room where he was evaluated, MRI studies were obtained and he
was treated with IV analgesic and discharged with instructions.
His overall lower back pain and sciatica symptoms continued to worsen further despite
these therapeutic maneuvers. Similarly, he was unable to return to work due to his pain.
soon thereafter he was referred to see Dr. Ravi Barnabas and Dr. Ruben Bermudez at
the Herron Medical Center, where he readily was evaluated, prescribed a course of
NSAID’s, and referred to us for further treatment, i.e., transforaminal epidural steroid
injections (TFESI’s).
Currently, his pain is described as a constant, “sharp, stabbing, shooting electrical-like
pain” which arises at the level of his distal lower back, and radiates caudally into his left
buttock as progresses further distally via a postero-lateral route into his left thigh, his left
calf and into his left ankle.
He denies allodynia, dysesthesia, hyperpathia, hyperalgesia, or any temperature
discrepancies between both upper and lower extremities. He denies as well fever, chills,
night sweats, nuchal rigidity, occipital headaches, dysphagia, jaw or tongue paresthesia,
balance disturbances, saddle anesthesia, vascular claudication, contralateral pain, drop,
or any bowel, bladder or sexual dysfunction of radicular origin. He acknowledges
moderate paresthesia manifested mostly as a “tingling sensation” throughout the leftsided L4-L5 dermatome. Similarly, he acknowledges frank neurological claudication as
well as foot drop, i.e., focalized weakness (3-4/5) to the left tibialis anterior, and the left
extensor hallucis longus (EHL) muscles.
He rates his pain as a 9-10/10 on the numeric pain scale (NPS) at its worst, and as a
6/10 on the same scale at its best. His level of pain increases significantly upon
ambulation as well as prolonged standing, sitting and bending.
One East Erie Street, Suite # 300
Chicago, IL. 60611
Phone: (312) 951-6471 Fax:(312) 649-5747
E-mail: [email protected]
www.rivernorthpmc.com
Page 2 of 4
Transfers also do seem to increase his pain level as well. His pain somewhat
ameliorates upon laying supine with the knees flexed. His sleep pattern has not been
affected by his pain. He denies any similar pain in the past.
PAST MEDICAL HISTORY: Mr. Wilson acknowledges history of CAD as he had an
acute myocardial infarction (AMI) in 2002. He also acknowledges untreated
hypertension. He denies asthma, diabetes, or thyroid disease.
PAST SURGICAL HISTORY: The patient denies any surgeries in the past.
MEDICATIONS: Aleve PRN.
ALLERGIES: Denies any allergies to any medications.
TOBACCO: He acknowledges history of smoking 15 cigarettes/day for more than
years.
ETOH: He drinks alcohol on a social basis; He denies history of alcohol substance
abuse
SOCIAL HISTORY: Mr. Wilson works for Timshel Construction as a bricklayer and tile
layer. He is separated and lives alone.
FAMILY HISTORY: Non contributory
REVIEW OF SYSTEMS: All systems were reviewed and found to be within normal
limits, with the exception of history of present illness.
PHYSICAL EXAMINATION: Mr. Wilson appears to be in mild to moderate distress. He
ambulates into the examining room with a mild limp which favors his left lower extremity;
he climbs onto the examining table at with some difficulty.
VITAL SIGNS: Blood pressure 140/82, respiratory rate 16, heart rate 82, and pulse
oximetry on room air 100%.
HEAD: Normocephalic, atraumatic.
EYES: PEERLA/EOMI’S intact.
FACE: Normal facial bone architecture. There is no evidence of droops, or
asymmetries.
NECK: Reveals no JVD, no bruit, no lymphadenopathies. Neck examination also
reveals a mildly reduced global excursion of the cervical spine. Inspection of the cervical
spine reveals no deformity, no gibbus, nor recent or remote trauma. Palpation
throughout the cervical as well as proximal thoracic spinal processes reveals no stepdowns and there is no tenderness elicited. Vertex compression test (Spurling test) and
L’Hermitte sign both were found to be negative. Costoclavicular maneuver, Wright and
Adson’s test were negative for thoracic outlet syndrome.
UPPER EXTREMITY: Reveals normal motor strength (5/5) throughout the different
muscle groups; Deep tendon reflexes response appear normal (2+/2+), throughout.
Upper extremity neurosensory examination when tested via pinprick response reveals
no decreased response throughout.
LUNGS: Clear to auscultation and percussion.
Page 3 of 4
HEART: S1 and S2 within normal limits.
ABDOMEN: Non-tender, non-distended.
BACK: On inspection there is no evidence of significant deformity, scoliosis, kyphosis,
lordosis or gibbus. There is no evidence of neither recent nor remote trauma.
Palpation throughout the distal thoracic and lumbosacral spine processes reveals no
step-downs and there is no tenderness elicited. Global excursion of the lumbosacral
spine reveals decreased forward flexion (40-50˚), normal lateral flexion (20˚-25˚), and
normal lumbar spinal extension (-25˚ to -30˚). Rotational exertion of the lumbo-sacral
spine when carried beyond 35˚ angle, i.e. facet loading maneuver does clearly yield
facet-like pain response. The patient is able to toe walk and heel walk with mild difficulty,
and is able to squat upon request with exacerbation of the pain.
Sciatic stretch tests, i.e. Straight leg (Lesegue sign), Braggard test; and Bechterew test
do elicit irritation response on the left. SLE appears reveals decrease elevation on the
left as well (40˚).
Gaenslen’s test, distraction maneuver, compression test, and Patrick/FABER maneuver
were found to be negative for SI joint dysfunction bilaterally. Piriformis test was found to
be negative bilaterally as well. The patient exhibits a Waddell score of 0/5.
LOWER EXTREMITY: Reveals normal motor strength (5/5) throughout the different
muscle groups, i.e., hip flexors, illiopsoas, hip abductors, Sartorius, Quadriceps,
Gastrocnemius/Soleus complex, toe dorsiflexors, toe dorsiextensors, and Gluteal
muscles bilaterally. There is some weakness noted (3/5) at the level of the biceps
femoris. There is also mild but relevant left-sided foot drop, i.e., focalized weakness (34/5) to the left tibialis anterior, and the left extensor hallucis longus (EHL) muscles.
The patient is able to adduct (30˚) and abduct (30˚-50˚) both hips as well. Deep tendon
reflexes reveal mild hyporeflexia (1+/2+) to the left patellar and Achilles tendon.
Repetitive stimulation of the Achilles tendon bilaterally does not yield clonus response.
The patient presents a bilateral Babinsky negative response. Neurosensory examination
when tested via pinprick response reveals subjective moderate decrease response
throughout the left L4-L5 dermatome.
Vascular examination reveals normal Femoral, Popliteal, posterior Tibilalis, and Dorsalis
Pedis pulses. There are no discrepancies between the temperatures on both lower
extremities when tested via temperature strip. There is no evidence of hyperalgesia,
hyperpathia, allodynia, or of myotrophic or skin atrophy either.
IMAGING STUDIES: An MRI obtained on 09/19/08 reveals: multilevel disk bulges and
facet arthopathy of the lumbo-sacral spine more pronounced at the L3-L4 and more so
L4-L5 where it results in central canal and neuroforaminal stenosis at this level.
IMPRESSION:
1.
2.
3.
4.
Multilevel lumbo-sacral spondylosis
L4-L5 central canal and neuroforaminal stenosis.
Left-sided L4-L5 radiculopathy.
Facet arthropathy
PLAN: Mr. Wilson's history, clinical presentation, physical and radiological findings, are
suggestive of a multilevel lumbosacral spondylosis, with associated multilevel disk
bulges and facet arthopathy of the lumbo-sacral spine more pronounced at the L3-L4
and more so L4-L5 where it results in central canal and neuroforaminal stenosis at this
Page 4 of 4
level.
Under this light, Mr. Wilson could benefit from a series of left-sided L4-L5 selective nerve
root block (SNRB)/Transforaminal epidural steroid injection (TFESI), as these carry far
more specificity to a single root therefore serving a dual purpose, i.e.,
diagnostic/therapeutic but also prognostic, should surgical decompression is entertained.
Additionally one cannot readily dismiss the fact that he has undoubtedly multilevel facet
arthropathy which could contribute to his overall pain. I doubt that his pain is other than
discogenic in origin and although degenerative facet arthropathy may play a relevant
role in the genesis of lower back pain, I fell that in Mr. Wilson’s case it might not be the
case; however one cannot readily disregard this possibility.
Should his overall pain and radicular symptoms persist despite the approach depicted
above, perhaps one should entertain the possibility of a diagnostic/therapeutic trial of
medial branch nerve blocks, which could determine the involvement of the facet
arthropathy in the genesis of his pain and guide subsequent management, i.e.
radiofrequency RF rhizotomy.
Today, I had a lengthy discussion with Mr. Wilson in reference to the risk versus benefits
ratio as well as real expectations associated with this procedure. I used a spine model
as well as computer generated graphics, to illustrate to him the technicalities involved in
the procedure as well as the remote complications associated with it. He understands
all of the above and consents for the procedure.
He additionally would benefit focused physical therapy, once his pain and radicular
symptoms subside, in order to strengthen his abdominal and paraspinous musculature
and therefore further increase his clinical improvement.
Sincerely,
Axel Vargas, M.D.
AV/yn
CC: Ravi .Barnabas, M.D.,
Dr. Ruben Bermudez
Herron Medical Center
1150 North State Street
Chicago, Illinois 60610
ATTY., Frank Cress
134 North LaSalle Street, Suite 444
Chicago, Il. 60606
Joe Wrozek (Adjuster) [email protected]
Chart