The patient comes in today for a follow-up visit. She continues to have chronic lower back pain and left knee pain. The worst pain is in her lower back at this point. She was given lumbar orthosis previously but she has been using them much. Pain level is 8-10/10 without medications and 5/10 with medications. She went to one physical therapy session thus far. Pain is mainly in the lower back and the axial part of the back in the lower lumbar spine. It is on the right greater than left side. She complains of occasional numbness and tingling in the lower extremities. She has pain in the left knee as well and a cortisone injection without much improvement. She had trigger point injection in the lumbar paraspinous muscles with temporary improvement. She denies any memory impairment, oversedation, constipation, nausea, itching, high or buzz on the medications. She is alert and functional with better quality of life since coming to the pain center. She is resting fairly well at night. She denies any change in her past medical history, past surgical history, medication history, allergies, family history, social history, or review of systems. She states she has not done physical therapy yet because her mother was sick and she also was sick over the last month.
Lumbar facet joint syndrome.
Patellofemoral syndrome in the left knee.
She must be compliant with physical therapy this month. She has no improvement in her back pain. We will recommend facet and SI injections. I have ordered her to use her lumbar orthosis no more than one hour a day and also began chiropractic treatments. I have renewed her Norco 7.5/325 mg one q.6h. as needed for pain, #120 dispensed. Again, I stressed compliance with therapy and chiropractic and the orthosis as I want to titrate her medications down as soon as possible. Again, if there is no relief in the pain, then we may consider medial branch blocks as well as possible SI joint injection.