She complains of a year and a half worth of neck and shoulder pain associated with some catching sensation in her left upper extremity, some on the right as well, predominantly stopping at the elbow with no sensation changes or muscle changes in her hands bilaterally.
This is a 67-year-old left-handed black female with chronic neck pain and left greater than right shoulder pain that started in February 2012. She denies any trauma or injuries associated with that condition. She states her pain is constant, sometimes creating her inability to sleep at night. She has a pain level of 6/10 and it currently is at level 6. She describes her back pain as a predominantly achy in nature. It is worse by cold and alleviated by heat. She states she has undergone physical therapy for six months with no relief. She states she has had chiropractic treatment in the past with no relief and a neck brace in the past with no relief. She has a complaint of neck pain as well that radiates into her head almost to the frontal area and this pain is aggravated by certain left physical exam maneuvers. She denies any other systemic conditions associated with this.
The patient had a SudoScan done today which showed higher than average asymmetry, left greater than right for peripheral neuropathy. The plan is to re-test the scan again three months and additionally she came in with an MRI report which shows multilevel cervical spondylitic changes present, worse at the C6-C7 level with some mild spinal cord compression. She had multilevel disc bulging as well and mild retrolisthesis at C6 on C7.
So my assessment is that she has SudoScan result which shows greater than average peripheral neuropathy, evidence of facet arthropathy left greater than right on physical exam with evidence of spondylotic changes on the MRI. My recommendation is that the patient and I discussed at length the possible treatment options, which include chiropractic treatments, acupuncture, and medical management including topical supply ointments and injection therapy which would include medial branch facet rhizotomy and/or cervical epidural injections. The patient at this time was not interested in injections, thereafter a detailed discussion of how they are performed and she states she would like to consider it and she would like to come back and discuss that with me in three weeks. My plan will be to see her in three weeks and if she agrees, we would set her up with the Center for cervical facet medial branch blocks at C3, C4, and C5 level and possibly third occipital nerve as well on the left side followed by facet rhizotomy if the results of the two medial branch block test are consistent with facet arthropathy. There are no other changes in the patient’s history or physical exam from previous. All of the patient’s questions were answered to her satisfaction and I will see her again in three weeks.