Reginald Davis, M.D., FAANS, FACS Director of Clinical ...

[Pages:145]Laser Spine Institute - Case Studies

Reginald Davis, M.D., FAANS, FACS ? Director of Clinical Research

Lumbar Decompressions

Case Study 1 - History

? A 48 year old female with a BMI of 23.16 presents for surgical evaluation of the lumbar spine

? Low back pain for 25 years, originating from a fall

? Reinjured in 2015 during exercise ? Tried conservative treatments (2 ESIs, chiropractic care, PT, and massage ? No prior surgery

? Complaints of low back pain that radiates to the right buttock/hip and the right posterior thigh. Numbness and tingling in all the toes on the right foot.

? Any prolonged position, lifting, and housework increases the pain

Physical Examination

? Spinal Exam

? Scar: No Scar ? Deep Tendon Reflexes: Patellar Left: 2+. Patellar Right: 2+. Achilles Left: 2+. Achilles Right: 2+. ? Pedal Pulses: Dorsalis Pedis: 2+. Posterior Tibial: 2+. ? LE Edema: No LE Edema ? UE Edema: No UE Edema ? Atrophy: No Atrophy ? Heel Walk: Left: Normal. Right: Normal. ? Toe Walk: Left: Normal. Right: Normal. ? Gait: Normal.

? Spinal Exam - Sensory / Palpation Dermatomes

? Left - Lumbar: Normal. ? Right - Lumbar: Normal. ? Spinal Tenderness ? Lumbar: L1/2: No Pain. L2/3: No Pain. L3/4: No Pain. L4/5: Right. L5/S1: Right. SIJ: No Pain.

Physical Examination Continued

? Spinal Exam - Range of Motion

? Lumbar-Thoracic: Flexion painful. Hyperextension painful. Lateral Flexion painful: Bilateral. Rotation painful: Bilateral.

? Spinal Exam - Provocative Tests

? Cervical Tests: Clonus Test - Left: Negative. Right: Negative. Hoffman's Test - Left: Negative. Right: Negative.

? Lumbar Tests: Babinski's Test - Left: Negative. Right: Negative. Lasegue's Test - Left: Negative. Right: Negative. Straight Leg Raise (Seated) - Left: Negative. Right: Negative.

? Both: Romberg Test - Negative.

? Spinal Exam - Muscle Strength

? Lumbar: Hip Abduction normal. Hip Adduction normal. Knee Flexion normal. Knee Extension normal. Gastrocnemius normal. Tibialis Anterior normal. Peroneals normal. Extensor Hallucis Longus normal.

Imaging Dictation

? L1-L2: No disc protrusion or spinal stenosis ? L2-L3: No disc protrusion or spinal stenosis ? L3-L4: The disc is severely narrowed and degenerated. There is a mild symmetric

disc bulge with mild central canal stenosis. Mild facet arthropathy present bilaterally. There is mild bilateral lateral recess stenosis. There is moderate foraminal stenosis on the right and severe on the left. The L3 nerve roots appear to be compressed (sagittal T2 images 5 and 10). ? L4-L5: There is a right foraminal disc protrusion. No central canal stenosis. There is mild bilateral lateral recess stenosis. There is mild right foraminal stenosis. The disc protrusion does not appear to be compressing the right L4 nerve root. No left foraminal stenosis. ? L5-S1: Disc space is narrowed. There is asymmetric disc bulge without compression of the thecal sac. Mild facet arthropathy is present. There is mild bilateral lateral recess stenosis, and moderate bilateral foraminal stenosis.

Preoperative Images

Preoperative Images Continued

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