3rd
March, 2023
MEDICAL
REPORT
O. G , 70 YEARS, MALE
HOSP
NO: WCA/4138/2023
BACKGROUND INFORMATION
A 70year old man known diabetic and hypertensive but reasonably controlled, currently on non-operative management of failed back surgery syndrome.
He had instrumented spine fusion surgery in 2009 for advanced degenerative disease of lumbo-sacral spine.
He is presently challenged with predominantly radicular lower back pain with neurogenic claudication features.
He presented today with complaints of lower waist pain of 2weeks duration, he describes his leg pains as pulling and quite discomforting to his basic comfort, he gets minimal relief bending over forward and use of lyrica lately, diclofenac isn’t helping with pain.
NEURO EXAM; Confirms limitation of straight leg raising on the left but the rest of motor sensory function appears normal.
Normal bowel and bladder function, however, not clear why he has rather persistent nocturia and frequency. Nil hesitancy, dribbling or decreased urine flow.
MANAGEMENT PLAN;
1. X-RAY lumbo-sacral spine and review (MRI cannot be performed because of convincing records to ascertain the nature of the nature of the pedicle implants with regards to MRI compatibility)
2. To continue physiotherapy
3. Step up pain ladder by receiving epidural injection with 80mg triamcinolone and 2.5mls 0.5%mercain.
4. For FBS, FBC, EUCR and FLP on Monday.
IMAGING AND DIAGNOSIS; X-ray of lumbo-sacrum and pelvis shows pedicle screws from L2-L5 with interbody spacers at the adjacent levels, nil evidence of instability.
Please note that you are scheduled for lumbar epidural injection on Monday 6th march, 2023 by 09:00am. You are also expected to come fasting for fasting blood sugar, fasting lipid profile, full blood count and electrolyte which is required before the procedure.
Lab investigations
findings done (06/03/20230)
FBC: WBC- 6.32, PCV- 41.02, PLT- 280
EUCR: Na- 137.8, K- 4.11, CL- 118.9, HCO3- 22.61, Cal- 2.23, Urea- 32.48, Cr- 0.62
FLP: Total cholesterol- 207.3, Triglyceride- 23.75, HDL- 50.33, LDL- 152.22
FBS: 5.23
MRI Lumbosacral spine revealed obvious evidence of previous instrumentation at L4/L5 as well as decompressed cauda equine from Laminectomy performed at those angles. There are also evidence of progression of degenerative changes at the other levels and those involving other element of spinal anatomy including but not limited to facet joint. There is also moderate entrapment of the exiting nerve root through the adjacent intra- vertebral canal.
This has been discussed with patient and emphasis on surgery risk-benefit analysis scale. Perhaps continuation of non-operative options is more pragmatic at this point.
Following his consent HE WAS SCHEDULED FOR EPIDURAL INJECTION- IMAGE GUIDED.
10/03/2023- He had epidural injection – Cocktail of 80mg triamcinolone and 0.25% marcaine. Well tolerated.
Review 72 hrs later shows a marginal improvement on pain score from 8/10 to 7/10. He was councilled on top op oral pain killers and need to return in a week for further assessment and discussion on need for further exposure to the cocktail.
Kindly revert for further clarifications
if need be.
Sincerely Yours,
Dr. Halima Ibrahim
For Team Wellington Clinics
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