SUBJECTIVE: The patient was seen in followup. It has been approximately two years since her severe closed head injury and over a year or so since her C5-C6 anterior cervical diskectomy and fusion. She did appreciate some improvement in left-sided strength and sensation, but she continues to have somewhat diffuse sensory deficit and some proximal weakness. After the anterior cervical diskectomy, all of her left shoulder pain completely resolved, but several months ago, the pain recurred. The pain tends to be worse with abduction of the left arm and lifting a heavier weight. The pain is primarily just below the shoulder, in the region of the deltoid insertion. It does not have any frank radicular component. There is no paresthesia with this.
OBJECTIVE: On examination, cervical range of motion was excellent. Foraminal compression test was vaguely positive on the left in the left paraspinal region. Muscle bulk, power, and tone were normal bilaterally, except for slight weakness, possibly secondary to discomfort in the left supraspinatus, deltoid, and biceps. Distally, she remains very strong. Deep tendon reflexes were 4+ bilaterally with spread. There were bilateral Hoffmann signs and bilateral clonus. Sensation was subjectively impaired over the left side, but this was primarily a cortical sensory loss with decreased stereognosis and two-point discrimination. Gait and balance was slightly unsteady.
DIAGNOSTIC STUDIES: Her cervical MRI scan demonstrates evidence of prior surgery at the C5-C6 level with very satisfactory decompression. There is no evidence of any nerve root or cord compression at any of the levels, most specifically at the C4-C5 level.
ASSESSMENT AND PLAN: Overall, we do not think she has any ongoing nerve root compression. We suspect that she most likely has some local shoulder pathology or rotator cuff injury. We are going to have her see Dr. John Doe as she has seen him in the past for hip condition.
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SUBJECTIVE: The patient returns to Neurosurgery Clinic. He is a pleasant (XX)-year-old gentleman who underwent L4-L5 anterior lumbar interbody fusion with femoral ring along with posterior translaminar facet screw fixation and left L5 decompression with Dr. John Doe. The patient tolerated the procedure well and ultimately experienced excellent results. He has had mild back spasms throughout the years. More recently, he was hospitalized with a severe spasm after he bent over to pick up an object. He was provided pain medication and over time his symptoms have subsided. Today, he is asymptomatic. He has undergone lumbar MRI and x-rays.
OBJECTIVE: On exam, the wounds have healed nicely. Lower extremities are full strength bilaterally throughout. Gait is symmetric and steady. The patient has overall good general coordination with symmetric tone and bulk throughout.
Lumbar MRI demonstrates expected postoperative changes and maturation of fusion, L4-L5. The canal is patent. There is no adjacent level disease. There is no indication of lumbar stenosis. X-rays demonstrate adequate positioning of screws and femoral ring. There is overall good alignment and spacing without indication of fracture instability.
ASSESSMENT AND PLAN: Overall, the patient is a pleasant (XX)-year-old gentleman who recovered well from anterior lumbar interbody fusion and posterior fixation. He experienced a significant spasm, which has since completely resolved. His imaging findings demonstrate stable postoperative changes. The imaging findings are shared in detail with the patient. We discussed with the patient, given his resolution of symptoms and normal radiographic studies, no intervention or diagnostic tests are recommended at this time. We have recommended the patient begin a formal physical therapy program for core muscle strengthening to avoid muscle spasm in the future. The patient is amenable to this plan. He will contact Neurosurgery as needed.
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SUBJECTIVE: This is a (XX)-year-old gentleman who comes in for evaluation of left upper extremity pain and weakness. He states that he had some difficulty with left shoulder pain. He underwent MRI imaging as well as an evaluation by orthopedic surgeon. Physical therapy was recommended without much benefit. He continued to have some difficulty with his left shoulder pain and again underwent more imaging as well as another course of physical therapy without much benefit. Over the past two years, he has had progressive difficulty with lifting of his left arm and over the past six months has had fairly significant weakness in the left shoulder. He describes pain in the left shoulder with really no radiation down the arm. He occasionally has some numbness and tingling in the upper arm that does not radiate below the elbow. He has generalized weakness throughout the left upper extremity, but most significantly in the left shoulder girdle. He feels that he may also have some weakness in the biceps. He denies any right upper extremity symptoms or gait instability. He denies any bowel or bladder symptoms. Aside from his previous physical therapy, he used to take anti-inflammatories on a regular basis, but discontinued this as he did not feel that it was helpful. He has not tried any other therapy. Overall, his symptoms have been fairly stable.
OBJECTIVE: This is a pleasant, well-developed, well-nourished, Hispanic gentleman in no acute distress. He has quite limited range of motion of the left upper extremity secondary to his weakness. Bilateral lower extremity strength is 5/5 throughout. Right upper extremity strength is 2/5 deltoid, 4/5 biceps, 4+/5 triceps, 4+/5 hand grip, 5/5 finger intrinsics and wrist flexion and extension. Sensation to light touch is intact bilaterally. Deep tendon reflexes are decreased and symmetric throughout all extremities. Babinski is downgoing bilaterally. No clonus is noted. Hoffmann is negative. The patient has a normal gait and is able to walk on his heels and toes without difficulty.
Review of C-spine MRI is notable for significant degenerative changes throughout the C-spine. There are multiple levels of disk protrusions, mostly towards the right. There does appear to be some left foraminal stenosis at C4-C5 secondary to disk protrusion as well as bony osteophytes. The patient has also undergone EMG testing. This shows evidence of C5 radiculopathy.
ASSESSMENT AND PLAN: These findings were reviewed with the patient. We explained to him that given the length of time that he had his weakness and the fact that he is showing muscle atrophy that it is very unlikely that his weakness will improve. In terms of treatment of his pain, we discussed therapeutic options including physical therapy, acupuncture treatment, chiropractic treatment without significant manipulation, epidural steroid injection, and surgery. As he has not had much improvement of his symptoms with physical therapy previously, we recommended that he consider an epidural steroid injection. This will be set up for him, left C7-T1 interlaminar epidural steroid injection. If his pain did not improve with this, he can contact us back and we can talk about surgical options. The patient agrees with this plan.
