MEDICAL
REPORT
F. C, 59 YEARS, FEMALE
WCA/6018/2023
Diagnosis-
Cervical and Lumbar Spondylotic Radiculopathy
Management Plan-
Conservative – counseling, bed rest, physiotherapy and medications
It
was a pleasure to review this 59yrs old female who had background history of
cervical spondylotic radiculopathy which has been well managed conservatively.
She is presently troubled by a rather acute onset of low back pain which
radiates predominantly to the right lower limb down to L5 and S1 dermatomes. Normal
bowel bladder functions. She walked to the clinic by herself with no obvious
gait abnormalities but accompanied by her husband. She seems to be in obvious
painful distress.
Neurological
exams confirms grade 4+/5 power most of the muscle groups on the right lower
limb and obvious paresthesia and shocking sensations to the right L5, L4 and S1
dermatomes. There is impairment of pin prick sensation in the L5/L4, S1
dermatomes
Radiological Imaging:
MRI
cervical spine shows mild
disc prolapse at C4/C5 causing thecal
indentation but does not interrupt free flow of CSF.
MRI
lumbosacral spine shows
preservation of lumbar lordosis. However, there is advanced disc degenerative
disease worse at L3/L4 and causing lost
of disc height, herniation, and thecal compression from the front. There is
also a hypertrophy of the ligamentum flavum at the same level and accentuating
cauda equine compression from the back. This severe canal stenosis is
reflecting on the myelogram which shows severe cauda equina compression at that
level. There is posterior-lateral herniation of this disc which is causing narrowing of exiting
nerve root at that level but mostly the traversing ones
Management
Plan:
·
To continue tabs gabapentin as
prescribed 1 tab twice daily
·
Tabs Cerebrex 200mg b.d x 1/52 (after
eating)
·
Tabs omeprazole 20mg b.d x 1/52
·
physiotherapy
Next follow up appointment is in 4
weeks (07/03/023)
Kindly revert for further
clarifications if need be.
Sincerely yours,
Dr.
Halima Ibrahim
For
Team Wellington Clinics.