Spine and Pain Case Studies 1
Oliver Ghalambor, MD, DABA, FIPP, DABIPP, DABPM
Case 1
57 year old female
Referred by Dr. Rios Chiropractor
Chief Complaint “Right Low Back and leg Pain”
Seen in consultation initially on 09/06/2017
Vitals: W 199lbs, H 65in, BMI 33.1, BP 151/89
Pulse 68, Pain 9/10 VAS
Past Medical History:
– DM
– Migraine/ Headaches
– High Cholesterol
– HTN
Non-smoker, occasional drinker
Employment: Texas Dept of Health and Human Services eligibility worker
Patient complained of back pain for 15 years.
Significantly worsened and is shooting down the right leg since 2 weeks prior.
History of MVA in 1999 and 2004
Pain is constant, burning, sharp, stabbing and tingling in the right leg
Previous treatment modalities tried:
– Adujustments
– Massage
– NSAIDs (Meloxicam), OTC meds
– Low dose narcotics (Norco and Tramadol) by PCP
– Muscle relaxant (Flexeril) by PCP
Positive findings on the exam:
– Positive SLR 10 degrees on the right, negative on the left side
– Decreased sensory to light touch and cold – temperature right L5 and S1 dermatomes
– Weakness 4+/5 right EHL, pain contributing
Reflexes 2+ bilateral knee, ankles
- Along with injections patient continued to have adjustments, therapy and massage under care of Dr. Rios
- Upon follow up, patient no longer had any weakness or numbness in her right leg, SLR became negative
-
Decided to proceed with Right sided L5 and S1 Transforaminal Epidural Steroid Injections
- 1st on 09/15/2017 > 70% relief of symptom
- 2nd on 10/20/2017 > 80% relief of symptom
- 3rd on 11/21/2017 > 90% relief of symptom
- This time minimal relief from her first epidural steroid injection, patient extremely miserable
- Referred to Dr. Benae, seen in consultation yesterday
Transforaminal Epidural Steroid Injection
- Patient was happy, no follow up with us needed, continued care under her chiropractor; however, patient experienced return of same symptoms; but much more severe on 04/20/17 suddenly without any trigger event.
- Exam on 04/25/17 Revealed a very miserable female unable to sit comfortable
- Positive SLR on the right side at 5 degrees
- Decreased sensory right L5 and S1 to light touch and cold temperature
- 4/5 Right ankle flexion, pain contributing
- Achilles reflex 2+ on the left, 1+ on the right
- Again recommended continuation of medical management and chiropractic care as well as proceed with another epidural steroid injection
- Obtain a new MRI of the lumbar spine
Case 2 Details
28 year Supervisor Auto body repair shop
Initial consultation 10/27/16
Found us by “Google search”
Chief Complaint “Low Back Pain”
Upon Exam he was unable to sit comfortably.
Rated the pain as 9/10.
Pain upon percussion of the low lumbar region.
Normal neurological exam.
Reported pain being there on and off for about a year
Started without any known trigger event
Worsened since 3-4 months prior
Saw Dr. K in Allen for three months to get Airrosti treatments
Pain was reported as Sharp in the low back, constant, occasionally radiating to both legs
Worse with sitting, driving, standing up holding his daughter.
Had tried Ibuprofen and Massage in addition to Airrosti treatments.
Prescribed muscle relaxant (Flexeril) 10 mg po qhs and hydrocodone 7.5-325 mg po tid prn.
First Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/01/2016 > 30% Relief
Second Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/29/2016 > 50% Relief
Third Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 12/27/2016 > 70% Relie
Pain is now “Tolerable”
Patient referred to Dr. Mills Chiropractor to start chiropractic therapy with adjustments and physical therapy
Emphasized importance of ongoing adjustments and physical therapy
No follow up with Pain needed
Happy camper
No PCP > Spine Surgeon > Surgery > More problems down the road
No High Dose Narcotics > Dependence > Addiction > Impact of life/ Job
However,
Return of symptoms in from of back pain 4 month later
Exam revealed positive facet loading maneuvers
Lumbar Facet blocks (Diagnostic)
