5th of February 2023.
TO WHOM IT MAY CONCERN
MEDICAL
REPORT
C.A, 59 YEARS, MALE,
WCA/1190/2015
Diagnosis: Chronic Low back pain
post spine surgery and instrumentation with background Parkinson’s disease.
·
Screw
malfunction (screw migration).
·
Failed
Back Syndrome.
Back
ground Presenting Information
The above-named patient was first seen by us in this
facility on the 4/9/2015. He has spine surgery and instrumentation in 2009 in
india. He has since been on neurology follow up on account of the background
Parkinson’s disease, however, he is also being managed conservatively (medical
management) for chronic low back pain.
He had an epidural injection done in 2017 which he
said relieved the pain but for a short period of time. He subsequently had
another epidural injection done on the 12/10/2022 following an MRI L/S scan
done which showed evidence of decompression with severe posterior bulge and
severe canal stenosis at L4/5 level with entrapment of exiting nerve root. He
was counseled on the need for a revision surgery but opted for the epidural
injection. However, he presented to the facility 4 months after the last
epidural with persistently worsening low back pain. He was counseled on the
need for another epidural injection which was administered today.
During the image guided epidural injection, images
obtained during the procedure showed evidence of screw migration at the L5
level such that the screw at that level is now in close proximity with the
cage. Correct placement of epidural needle before injection of medication.
Images displayed below.
Further management of the patient would include
·
CT lumbosacral spine
·
For possible back revision surgery on
account of failed back syndrome with failed epidural injection.
He has been counseled on the diagnosis and further
management plan.
Dr
Chizim Mordi MD
For Team Wellington Clinics Abuja