Neck and mid back pain

The patient is very pleasant 72-year-old self-referred female with chronic pain from her head down to her low back. She states that she has had MRIs of her brain, cervical spine, thoracic spine and lumbar spine but “no diagnosis has even been give to her” regarding all of her issues. As it took more than 30 minutes for her to fill out the paperwork, we only had 30 minutes left for our evaluation today.

The patient states that she has had progressively worsening headaches that are in a Ram’s Horn distribution. She has a history of glaucoma and does not notice that the pain refers into her eye from her skull or whether or not it is related to the glaucoma itself. She states she has been diagnosed with narrow angle glaucoma but did have surgery for this and is unsure whether or not she continues to have narrow angle glaucoma. She has been utilizing gabapentin 300 mg q.h.s. for “myofascial pain” in the evening. This has not helped much.

She describes pain in the neck, radiating head pain towards the eye, as well as pain in the interscapular area and down to low back. She presents today for evaluation.

PAST MEDICAL HISTORY:
The patient denies.

PAST SURGICAL HISTORY:
Laser surgery of the eyes for narrow angle glaucoma and a hernia repair.

ALLERGIES:
No known drug allergies.

CURRENT MEDICATIONS:
Gabapentin.

FAMILY HISTORY:
Heart disease.

SOCIAL HISTORY:
She has occasional wine and denies use of tobacco. No creational drugs. She is retired since June 2010. She is married, with two children and has a high school education.

DIAGNOSTIC STUDIES:
The patient has MRI of the brain, cervical spine, thoracic spine and lumbar spine available today. I was able to produce the cervical MRI in office today. This does show straightening of the spine with multilevel degenerative spondylosis and degenerative disc disease. There does appear to be fluid in the higher zygapophyseal joints and suspected cervical facet syndrome. The other imaging studies were not visualized by myself.

ASSESSMENT:
This is 72-year-old female with primary complaint of head, neck and interscapular pain. She does have other issues, but we do not have time to address them all today

IMPRESSION:
1. Cephalalgia; most likely referred from the C2-C3 joint and presenting as a greater occipital neuralgia.
2. Cervicalgia; most likely somatic dysfunction without any evidence of issues in the neuraxis from MRI.
3. Interscapular pain; most likely somatic in nature.
4. Narrow angle glaucoma with recent surgery; may provide some pain in the periorbital area, but this also may be referred from the greater occipital nerve.

PLAN:
I had a very nice visit with the patient and her husband today. We talked about taking wait and see approach versus medication management versus physical rehabilitation modalities versus further diagnostic imaging versus interventional pain therapies.

My advice at this point would be to perform bilateral in-office greater occipital nerve blocks with local anesthetic glucocorticoid. If this is unsuccessful, then we may consider treating the source of the pain by performing cervical zygapophyseal joint injections from C2 through C4 as I feel that she will ultimately be a good candidate for radiofreqency neuroablation in long run. I would like to consider physical rehabilitation in the form of chiropractic and physical therapy for her somatic dysfunction in the neck and upper back but she has already been through extensive physical therapy, which she states did not help in the long run. I will move forward with authorizing bilateral greater occipital nerve blocks for now trying to treat this pain indirectly and we will take a look at her low back at a later time. She is in agreement with this plan and I will see her back for bilateral greater occipital nerve block or bilateral C2-C4 cervical zygapophyseal joint injection if the patient desires any ambulatory surgery center under fluoroscopic guidance. She seems very happy with the visit today. I will look forward to work with her.

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