Work Related Injury: Case Study

Review # 256622

DOI: 8/19/2008. The patient is a 64-year old male stock driver who sustained a work-related injury due to stress of employment. The patient was subsequently diagnosed with Degenerative Disc Disease lumbar spine, radiculopathy. As per office notes dated 01/12/2016 revealed that the patient complains of worsening lower back pain. He is having difficulty bending to the right which causes a little more pain. He has been taking Norco 10/325mg approximately three to four times a day. He has great difficulty with range of motion of the lower back. Movements such as rotation, as well as flexion and extension do cause some pain and discomfort. Pain can be sharp or dull at times. In addition, the patient reports that pain radiates

downwards into the bilateral lower extremities. Upon examination, there is very mild loss of lumbar lordosis. No central tenderness but paraspinous tenderness is noted. There is decreased flexion and extension of the lumbar spine and a positive straight leg raise sign. Furthermore, there is mild strength deficit in musculature. Per MRI dated 2/10/16, impression revealed multilevel degenerative disc disease, moderate to severe central spinal canal with right lateral recess and moderate bilateral foraminal stenosis at L4-5, and moderate central spinal canal stenosis at L2-3 and L3-4. As per office notes dated 3/29/15, patient continues to struggle with respect to pain and discomfort in the lumbar spine. There is a great difficulty mobilizing the lower back. Pain and discomfort were reported for rotation, in addition to flexion and extension. Examination of the lumbar spine reveals very mild loss of lumbar lordosis and praspinous tenderness with no central tenderness. Decreased flexion and extension of lumbar spine is noted as well as positive straight leg raise. There is mild strength deficit in musculature. As per provider's recommendation, patient will continue with careful activity and to be transferred completely to a dedicated spine specialist that can be either within the field of surgery or physical medicine and rehab would be beneficial for the patient. In addition to this, there is a possibility that a lumbar block may be needed.

Current request is 1 Transfer of Care to a Spine Specialist between 4/7/2016 and 6/6/2016.

Based on the medical documents submitted and the specified treatment guidelines on the injured body part, the request for transfer of care to a spine specialist is medically necessary. The patient continues to struggle with respect to pain and discomfort in the lumbar spine. There is a great difficulty mobilizing the lower back. Pain and discomfort were reported for rotation, in addition to flexion and extension. Examination of the lumbar spine reveals very mild loss of lumbar lordosis and praspinous tenderness with no central tenderness. Decreased flexion and extension of lumbar spine is noted as well as positive straight leg raise. There is mild strength deficit in musculature. Per MRI dated 2/10/16, impression revealed multilevel degenerative disc disease, moderate to severe central spinal canal with right lateral recess and moderate bilateral foraminal stenosis at L4-5, and moderate central spinal canal stenosis at L2-3 and L3-4. Per ACOEM, providers with patients that appear to be heading towards chronic pain & if referral of a patient to other specialists may benefit from additional expertise, a referral to appropriate providers is strongly advised. Therefore, the request for Transfer of Care to a Spine Specialist is medically necessary.

CA MTUS
ACOEM Independent Medical Examinations and Consultations
ODG