Bilateral lower extremity pain

The patient is very pleasant 74-year-old white female with complaints of bilateral left greater than right lower extremity pain and paraesthesias. She has non-insulin dependant diabetes and has undergone multilevel lumbar fusion. She is a very poor historian with regards to her back surgery, but she does have a cicatrix extending from just inferior from the bra line down to the sacrum. She states that her fusion surgery was approximately six years ago and it was at multiple levels and did involve scoliosis correction and stenosis.

She had a spinal cord stimulator trial with a female physician in Freehold and ultimately the spinal cord stimulator was implanted with her neurosurgeon in October 2012. She states that this never worked and she is not using it at all any more. She subsequently had x-rays performed, which showed that the stimulator did not move, but it is not working and she has it turned off.

She states that the pain in her legs has been very bad for the last three to four years, specifically in the bottom of her left foot. She also notices weakness in her legs with early fatigue when standing or ambulating up. She presents today for evaluation.

ASSESSMENT:
This is 74-year-old female with a mixed pain complaint of bilateral lower extremity paraesthesias.

IMPRESSION:
1. Chronic lumbosacral radiculopathy; the patient has spinal cord stimulator in situ.
2. Suspected diabetic peripheral neuropathy; the patient has been diagnosed with non-insulin-dependent diabetes for the last few years with fairly well-controlled hemoglobin A1c level.
3. Status post multilevel thoracolumbar fusion; no diagnostic studies regarding exact location.
4. Non-insulin-dependent diabetes.

PLAN:
I feel at this point that her pain is mixed between diabetic peripheral neuropathy as well as lumbosacral radiculopathy. The patient does not want an EMG study due to the discomfort that she has had having EMG studies prior to her surgery.

We discussed taking wait and see approach versus medication management versus physical rehabilitation modalities versus further diagnostic imaging versus interventional pain therapies. At this point, I feel the she will be an appropriate candidate for P-Stim trial prior to consideration of lumbar sympathetic block and ultimately neurolysis. I feel that the majority of her discomfort at this time is coming from the diabetic peripheral neuropathy. I did advise her to obtain the imaging studies so we can see whether the spinal cord stimulator needs to be replaced if they may have migrated since implantation.

I gave her handout regarding P-Stim device and also handwrote my recommendation for the trial of the P-Stim device prior to consideration of lumbar sympathetic block. We also discussed the possibility of intrathecal pain pump just to let her know there are various modalities available to treat her chronic pain in the long-term.

The patient seems very happy with the visit today. I look forward to work with her. I advised her to follow up with Dr.for P-Stim implantation.

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