Carpal tunnel syndrome, bilateral

The patient is a 60-year-old male who presents with complaint of cervical pain that radiates down into both upper extremities and also a diagnosis of carpal tunnel syndrome. He also has a history of low back pain with lumbar surgery and spinal cord stimulator. We are working on him on his neck and upper extremity pain. He is scheduled for an EMG but it has not been done yet. Patient did have a CT scan. I discussed the CT scan findings with him. My recommendation was to undergo a series of cervical epidural steroid injections. He understand that there is no guarantee that they will eliminate the pain because he does have some spinal stenosis symptom in the cervical spine due to a combination of factors that include osteophytes and disc bulging along with uncovertebral joint arthropathy. He understands this and is willing to proceed. The cervical epidural steroid injection will be scheduled until after the September 15, 2011 since he is having eye surgery.

ASSESSMENT:
1. Obesity.
2. Carpal tunnel syndrome, bilateral.
3. Cervicalgia.
4. Cervical spinal stenosis.
5. Cervical uncovertebral arthropathy.
6. Failed back syndrome.
7. Peroneal neuropathy.

RECOMMENDATIONS:
After discussing with the patient the risk, benefit, alternative and technical aspect of the performance of the cervical epidural steroid injection, the patient agreed to undergo this treatment. He will be scheduled for cervical epidural steroid injection at the surgery center after the September 15, 2012. He is having surgery on his eye for a defective retina and would like to have this done afterward. We agree to proceed that way.

I started him on Gralise trial. He will take 600 mg every night with food. He was instructed to increase it to 600 mg twice a day if after a week of taking 600 mg everyday he experiences no improvement. A free sample was given to the patient.

Continue physical therapy.

Physical therapy has been helping with the range of motion and pain in the low back as well as the cervical area.

Followup with EMG. I will review the EMG report and discuss it with the patient at appropriate time.

Followup after the cervical epidural steroid injection.

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