Bilateral lower extremity paresthesias; highly consistent with lumbosacral radiculopathy

The patient is a very pleasant 66-year-old female who comes today for consultation for suspected “neuropathy.” After some preliminary questioning, it appears that this is a chronic lumbar radiculopathy and not a peripheral neuropathy. She appeared to be somewhat confused about the definition of peripheral neuropathy versus lumbosacral radiculopathy. She denies any diabetes, HIV, chemotherapy, toxin exposure or excessive alcohol use at this time.

The patient had undergone anterior and posterior L4 through S1 instrumented fusion two years ago secondary to stenosis and spondylolisthesis. She has chronic paresthesias distally throughout the bilateral lower extremities and presents today for evaluation.

She did undergo a caudal epidural steroid injection approximately a year ago which helped significantly, but she did not repeat that injection this past year due to the corticosteroid scare from the independent pharmacy in Massachusetts. She states that her pain in her legs is exacerbated with sitting, standing or walking for greater than 30 minutes. Pain will shoot up her legs and even goes into the left buttock.

ASSESSMENT:
This is a 66-year-old female who presents today with “neuropathy” but this is surely lumbosacral radiculopathy.

IMPRESSION:
1. Bilateral lower extremity paresthesias; highly consistent with lumbosacral radiculopathy.
2. Status post anterior and posterior L4 through S1 instrumented fusion.

PLAN:
I had a very lengthy visit with the patient today. We discussed taking await and see approach versus medication management versus physical rehabilitation modalities versus diagnostic tests such an EMG versus interventional pain treatments.

Seeing that she is hurting and that a caudal epidural helped her approximately a year and half ago, I feel that it is appropriate to do a caudal epidural steroid injection again. She can have that done. In the long-term, if she does not do well from the injected glucocorticoid, I would highly recommend a trial of neuromodulation. I did provide her with a handout and DVT regarding neuromodulation. She will review on her own.

She seemed very happy with the visit today and hopefully the caudal epidural steroid injection will help her. If not, we can refer her to more advanced modalities if needed.

She seems very satisfied with the same and I will look forward to work with her.

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