INFUSE BONE GRAFT
Report
- Report Number
- 1030489-2014-03029
- Event Type
- Injury
- Date Received
- July 7, 2014
- Report Date
- August 3, 2015
- Manufacturer
- MEDTRONIC SOFAMOR DANEK USA, INC
- Product Code
- NEK
- PMA / PMN Number
- P000058
- Adverse Event
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- TX, US
- Reporter Occupation
- ATTORNEY
Narratives
(B)(4). NEITHER THE DEVICE NOR FILMS OF APPLICABLE IMAGING STUDIES WERE RETURNED TO THE MANUFACTURER FOR EVALUATION. THEREFORE, WE ARE UNABLE TO DETERMINE THE DEFINITIVE CAUSE OF THE REPORTED EVENT. PRODUCTS FROM MULTIPLE MANUFACTURERS WERE IMPLANTED DURING THE PROCEDURE. ALTHOUGH IT IS UNKNOWN IF ANY OF THE DEVICES CONTRIBUTED TO THE REPORTED EVENT, WE ARE FILING THIS MDR FOR NOTIFICATION PURPOSES.
(B)(6). (B)(4).
IT WAS REPORTED THAT ON (B)(6) 2004: PATIENT UNDERWENT FLEXIBLE SIGMOIDOSCOPY/ATTEMPTED COLONOSCOPY. ASSESSMENT: ATTEMPTED COLONOSCOPY. INCOMPLETE PREP ASSOCIATED WITH POOR COMPLIANCE. COLON POLYPS. ON (B)(6) 2004: PATIENT PRESENTED WITH HISTORY OF COLON POLYPS AND UNDERWENT COLONOSCOPY AND HOT BIOPSY. NO COMPLICATIONS REPORTED. ASS ESSMENT: COLONOSCOPY TO CECUM; COLON POLYPS, CAUTERIZED. ON (B)(6) 2004: PATIENT PRESENTED REGARDING AN INCISIONAL HERNIA. PATIENT HAD EXPLORATORY LAPAROTOMY WITH COLOSTOMY AND HAD NOW DEVELOPED PAINFUL SWELLING IN THE UPPER PORTION OF THE MIDLINE INCISION. PATIENT COMPLAINED OF ESOPHAGEAL REFLUX. IMPRESSION: PATIENT WITH INCISIONAL HERNIA. ON (B)(6) 2004: PATIENT PRESENTED WITH PRE-OP DIAGNOSIS OF INCARCERATED INCISIONAL HERNIA. PATIENT UNDERWENT INCARCERATED INCISIONAL HERNIA REPAIR WITH PROLENE MESH. THERE WERE NO COMPLICATIONS. ON (B)(6) 2007: PATIENT PRESENTED WITH LEFT KNEE PAIN. PATIENT COMPLAINED OF OCCASIONAL GIVING WAY AND CRACKING AND POPPING. ASSESSMENTS: CHONDROMALACIA PATELLAE. ON (B)(6) 2007: PATIENT PRESENTED WITH RADICULOPATHY AND MRI EVIDENCE OF CORD AND ROOT COMPRESSION. PATIENT FAILED CONSERVATIVE TREATMENT. PRE-OP DIAGNOSIS: SEVERE SPINAL STENOSIS C4-C5 AND C5-C6. PATIENT UNDERWENT FOLLOWING PROCEDURES: ANTERIOR CERVICAL DISCECTOMY, C4-C5, C5-C6. ANTERIOR CERVICAL FUSION, C4-C5, C5-C6. PLACEMENT OF INTERBODY SPACER X2. ANTERIOR INSTRUMENTATION, C4-C5-C6. AUTOGRAFT. UTILIZATION OF FLUORO. RECURRENT LARYNGEAL NERVE MONITORING. PER OP NOTES, INTERBODY SPACER OF APPROPRIATE SIZE WITH RHBMP-2/ACS PLACED CENTRALLY WAS THEN PLACED IN THE C4-C5 INTERSPACE. AP AND LATERAL RADIOGRAPH WERE TAKEN AT THIS TIME TO CONFIRM APPROPRIATE PLACEMENT OF HARDWARE AND BONE GRAFT. NO COMPLICATIONS REPORTED. ON (B)(6) 2007: PATIENT PRESENTED FOR POST-OP EVALUATION. ASSESSMENT: CERVICAL ARTHRITIS. ON (B)(6) 2008, (B)(6) 2009, AND (B)(6) 2010: PATIENT PRESENTED FOR FOLLOW UP. PATIENT ADMITTED FATIGUE, LUMBAR BACK PAIN, JOINT PAIN. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: CERVICALGLA; OTHER AND UNSPECIFIED HYPERLIPIDEMIA; DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED; ESOPHAGEAL REFLUX; BACK PAIN ,LUMBAR; SCIATICA; LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS; VITAMIN D DEFICIENCY; SCREENING FOR MALIGNANT NEOPLASMS OF THE PROSTATE; COUGH; VIRAL WARTS UNSPECIFIED; SYNCOPE <(>&<)> COLLAPSE. ON (B)(6) 2008: PATIENT PRESENTED FOR FOLLOW UP WITH NECK PAIN. PATIENT REPORTED OCCASIONAL NUMBNESS IN HANDS. ASSESSMENT: CARPAL TUNNEL SYNDROME. CUBITAL TUNNEL SYNDROME. ON (B)(6) 2008: PATIENT PRESENTED FOR FOLLOW UP WITH NECK PAIN. PATIENT REPORTED OCCASIONAL NUMBNESS IN HANDS. PATIENT UNDERWENT EMG AND NC STUDIES. RESULT: MILD LEFT CTS. PATIENT UNDERWENT LEFT HAND X-RAY WHICH SHOWED MILD BASAL JOINT ARTHRITIS. ASSESSMENT: CARPAL TUNNEL SYNDROME. HAND ARTHRITIS. ON (B)(6) 2008: PATIENT PRESENTED WITH DIARRHEA, RECTAL BLEEDING. PATIENT UNDERWENT COLONOSCOPY AND BIOPSY AND HOT BIOPSY. ASSESSMENT: COLONOSCOPY TO CECUM; MULTIPLE COLON POLYPS; MODERATE PREP. ON (B)(6) 2008: PATIENT PRESENTED FOR FOLLOW UP. PATIENT ADMITTED FATIGUE, LUMBAR BACK PAIN, AND JOINT PAIN. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: UNSPECIFIED DISORDER OF PROSTATE; OTHER AND UNSPECIFIED HYPERLIPIDEMIA; DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED; BACK PAIN, LUMBAR; PAIN IN LIMB; MYALGIA AND MYOSITIS UNSPECIFIED; CRAMP OF LIMB. ON (B)(6) 2008: PATIENT PRESENT WITH ACUTE PROBLEM OF DIZZINESS. PATIENT FELT OFF BALANCE. PATIENT ADMITTED FATIGUE, LUMBAR BACK PAIN, AND JOINT PAIN. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: DIZZINESS AND GIDDINESS; OTHER AND UNSPECIFIED HYPERLIPIDEMIA; DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED; SYNCOPE <(>&<)> COLLAPSE; UNSPECIFIED ESSENTIAL HYPERTENSION. ON (B)(6) 2009: PATIENT PRESENTED WITH ACUTE DERMATOLOGIC SYMPTOMS. DIAGNOSES: CLOSED FRACTURE OF ONE RIB; SPINAL STENOSIS OF LUMBAR REGION; BACK PAIN, LUMBAR; VIRAL WARTS UNSPECIFIED. PATIENT UNDERWENT DESTRUCT LESION PROCEDURE. ON (B)(6) 2010: PATIENT UNDERWENT BONE STUDY EXAM. IMPRESSION: BONE MINERAL DENSITY WAS MEASURED IN THE LUMBAR SPINE AND FEMORAL NECK. BY WORLD HEALTH ORGANIZATION CRITERIA THIS PATIENT HAS OSTEOPENIA. COMPARED TO EARLIER EXAM IN 2007, BONE DENSITY IS DECREASED. POSSIBILITY OF PHARMACOLOGICAL THERAPY TO MAINTAIN OR IMPROVE BONE DENSITY MAY BE CONSIDERED. FOLLOW-UP EXAMINATION IS RECOMMENDED IN TWO YEARS. ON (B)(6) 2010: PATIENT PRESENTED FOR FOLLOW UP AND HAD BEEN CONGESTED AND COUGHING FOR ABOUT ONE MONTH. PATIENT WAS STILL HAVING A LOT OF NECK PAIN. PATIENT ADMITTED FATIGUE, LUMBAR BACK PAIN, JOINT PAIN, COUGHING. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: CERVICALGLA; OTHER AND UNSPECIFIED HYPERLIPIDEMIA; DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED; ESOPHAGEAL REFLUX; BACK PAIN ,LUMBAR; SCIATICA; LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS; VITAMIN D DEFICIENCY; OTHER MALAISE AND FATIGUE; BIPOLAR AFFECTIVE DISORDER UNSPECIFIED. ON (B)(6) 2010: PATIENT UNDERWENT CHEST X-RAY. IMPRESSION: NO ACUTE PROCESS. ON (B)(6) 2010: PATIENT PRESENTED FOR FOLLOW UP WITH COMPLAINING A POSTERIOR AXIAL TYPE NECK PAIN. ASSESSMENT: CERVICAL ARTHRITIS; CERVICAL SPINE DDD; CERVICALGIA. ON (B)(6) 2010: PATIENT UNDERWENT MRI OF CERVICAL SPINE. IMPRESSION: MILD DEGENERATIVE DISC AND JOINT DISEASE WITH POST SURGICAL CHANGES IN THE MID CERVICAL SPINE. ON (B)(6) 2010: PATIENT PRESENTED FOR FOLLOW UP AND NOTED SOME 'INCREASE IN DAYTIME FATIGUE. PATIENT HAD NOT BEEN SLEEPING WELL. PATIENT ADMITTED LUMBAR BACK PAIN, JOINT PAIN, NECK PAIN. DIAGNOSES: CLAUDICATION; PERSISTENT DISORDER OF INITIATING OR MAINTAINING SLEEP; OTHER AND UNSPECIFIED HYPERLIPIDEMIA; POLYURIA; DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE UNCONTROLLED; LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS; DIZZINESS AND GIDDINESS; OTHER MALAISE AND FATIGUE; VITAMIN D DEFICIENCY. ON (B)(6) 2010: PATIENT WAS ADMITTED DUE TO CHEST DISCOMFORT. ON (B)(6) 2010: PATIENT UNDERWENT SLEEP STUDY. DIAGNOSTIC IMPRESSION: CLINICALLY SIGNIFICANT REM RELATED OBSTRUCTIVE SLEEP APNEA WITH OXYGEN DESATURATIONS TO THE MID 80'S. HEAVY SNORING. ON (B)(6) 2010: PATIENT UNDERWENT SINGLE ISOTOPE PERFUSION NUCLEAR STRESS IMAGING STUDY DUE TO DIAGNOSES OF CHEST PAIN AND DIABETES. IMPRESSION: NO EVIDENCE FOR ANY SIGNIFICANT ISCHEMIA. NORMAL LV FUNCTION LOW PROBABILITY OF OCCLUSIVE CORONARY DISEASE, ALTHOUGH IT IS POSSIBLE THAT THE PATIENT MAY HAVE SOME DISEASE BASED ON HIS RISK FACTORS. ON (B)(6) 2010: PATIENT UNDERWENT LOWER EXTREMITY ARTERIAL STUDY DUE TO INTERMITTENT CLAUDICATION. CONCLUSION: NORMAL LOWER EXTREMITY ARTERIAL STUDY. NO EVIDENCE OF SIGNIFICANT PERIPHERAL VASCULAR OCCLUSIVE DISEASE. PATIENT ALSO UNDERWENT CHEST X-RAY. IMPRESSION: NO OBVIOUS ACUTE ABNORMALITY; HOWEVER, PULMONARY CT IS SUGGESTED TO EXCLUDE A NODULAR DENSITY RIGHT LUNG. ON (B)(6) 2010: PATIENT PRESENTED FOR FOLLOW UP AND NOTED SOME PERSISTENT CLAUDICATION. PATIENT ADMITTED FATIGUE, CHEST PAIN/PRESSURE, LUMBAR BACK PAIN, JOINT PAIN, COUGHING. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: CERVICALGLA; OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC); DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED; CHEST PAIN, OTHER; NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD; SPINAL STENOSIS OF LUMBAR REGION. ON (B)(6) 2010: PATIENT UNDERWENT CT OF THE CHEST WITH CONTRAST DUE TO DENSITY RIGHT FIFTH RIB. IMPRESSION: LOW-GRADE ATELECTASIS OR SCARRING IN THE RIGHT MIDDLE LOBE HUT NO SUSPICIOUS MASS OR ADENOPATHY. ON (B)(6) 2010: PATIENT PRESENTED FOR FOLLOW UP WITH SOME RECURRENT EPISODES OF CHEST TIGHTNESS. PATIENT DID HAVE SOME COUGH WITH THICK SPUTUM. PATIENT ADMITTED HEART BURN, CHEST PAIN/PRESSURE, NASAL CONGESTION, LUMBAR BACK PAIN, JOINT PAIN. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: SPINAL STENOSIS OF LUMBAR REGION; CHEST PAIN; LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS; COUGH; OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC); ESOPHAGEAL REFLUX.. ON (B)(6) 2010: PATIENT PRESENTED FOR FOLLOW UP WITH INTERMITTENT CHEST PAIN. PATIENT ADMITTED FATIGUE, SLEEP DISTURBANCE, CHEST PAIN/PRESSURE, LUMBAR BACK PAIN, JOINT PAIN, COUGHING. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: CERVICALGLA; OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC); DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED; CHEST PAIN, OTHER; BACK PAIN, LUMBAR; OTHER AND UNSPECIFIED HYPERLIPIDEMIA. ON (B)(6) 2011: PATIENT PRESENTED FOR FOLLOW UP. PATIENT REPORTED FEELING AWFUL AND HAVING CONGESTION. PATIENT ADMITTED NASAL CONGESTION, FATIGUE, SLEEP DISTURBANCE, NASAL DISCHARGE, SORE THROAT, CHEST PAIN/PRESSURE, LUMBAR BACK PAIN, JOINT PAIN, COUGHING. PALPATION OF THE NECK SHOWS IT IS SUPPLE, WITHOUT ADENOPATHY OR MASSES. THERE WAS TENDERNESS AND SPASM NOTED OF THE LUMBAR PARASPINAL MUSCLES. RANGE OF MOTION OF LUMBAR SPINE IS RESTRICTED SECONDARY TO PAIN. DIAGNOSES: CERVICALGLA; OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC); DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED; BACK PAIN, LUMBAR; ACUTE BRONCHITIS; OTHER AND UNSPECIFIED HYPERLIPIDEMIA; VITAMIN D DEFICIENCY. ON (B)(6) 2011: PATIENT PRESENTED WITH UPPER RESPIRATORY SYMPTOMS. PATIENT ADMITTED NASAL CONGESTION, FATIGUE, COUGHING, AND HEADACHE. DIAGNOSIS: "URI". ON (B)(6) 2011, AND (B)(6) 2012: PATIENT PRESENTED FOR FOLLOW UP. DIAGNOSES: CERVICALGLA, OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC). ESOPHAGEAL REFLUX,. UNSPECIFIED ESSENTIAL HYPERTENSION, DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED, LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS. CHEST PAIN, BACK PAIN. OTHER MALAISE AND FATIGUE. OTHER AND UNSPECIFIED HYPERLIPIDEMIA, VITAMIN D DEFICIENCY, DIZZINESS <(>&<)> GIDDINESS. ON (B)(6) 2012: PATIENT PRESENTED FOR FOLLOW UP VISIT. PATIENT COMPLAINED OF NUMBNESS AND TINGLING ALL OVER THE BODY. PATIENT REPORTED BALANCE ISSUE AND A LOT OF NECK PAIN. PATIENT NOTED THAT THE ARMS WERE WEAK. DIAGNOSES: CERVICALGLA., POLYNEUROPATHY IN DIABETES, BIPOLAR AFFECTIVE DISORDER UNSPECIFIED, ANXIETY STATE UNSPECIFIED, UNSPECIFIED ESSENTIAL HYPERTENSION, DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED. ABNORMALITY OF GAIT. ON (B)(6) 2012: PATIENT PRESENTED FOR FOLLOW UP. PATIENT HAD CONCERNS WITH THE TREMORS IN HIS HANDS, NUMBNESS IN HIS FINGERS ON BOTH HANDS. HIS FEET HAD A BURNING SENSATION IN THEM. PATIENT WAS HAVING SOME INTERMITTENT CHEST PAIN IN THE RIGHT JAW AT TIMES. THE PAIN WAS NOT REALLY EXERTIONAL BUT HAD NO REAL PATTERN. DIAGNOSES: CERVICALGLA, POLYNEUROPATHY IN DIABETES, BIPOLAR AFFECTIVE DISORDER UNSPECIFIED, ANXIETY STATE UNSPECIFIED, UNSPECIFIED ESSENTIAL HYPERTENSION, DIABETES MELLITUS WITHOUT COMPLICATION TYPE II OR UNSPECIFIED TYPE NOT STATED AS UNCONTROLLED. ABNORMALITY OF GAIT, PAIN IN LIMB, CHEST PAIN, OTHER MALAISE AND FATIGUE, OTHER AND UNSPECIFIED HYPERLIPIDEMIA. ON (B)(6) 2013: PATIENT PRESENTED FOR LUMBAR SPINE RECHECK WITH MODERATE BACK PAIN. ASSESSMENT: LUMBAR DDD; CERVICAL SPINAL STENOSIS; CERVICAL DISC DISPLACEMENT; LUMBAR STENOSIS.
IT WAS REPORTED THAT ON (B)(6) 2004, THE PATIENT PRESENTED WITH A HISTORY OF COLON POLYPS. THE PATIENT UNDERWENT A FLEXIBLE SIGMOIDOSCOPY / ATTEMPTED COLONOSCOPY. THE PROCEDURE WAS NOT COMPLETED AS THE PATIENT HAD NOT DONE THE PREP. ON (B)(6) 2004 THE PATIENT UNDERWENT A COLONOSCOPY AND HOT BIOPSY PROCEDURE WHICH SHOWED SEVERAL SMALL POLYPS IN THE DESCENDING COLON AND A 5-6 MM SESSILE POLYP. ON (B)(6) 2004 THE PATIENT PRESENTED WITH AN INCISIONAL HERNIA. PER THE ENCOUNTER NOTE THE PATIENT HAD A HISTORY OF ACCIDENTAL GUNSHOT WOUND TO THE ABDOMEN (20 YEARS PRIOR) AND EXPLORATORY LAPAROTOMY WITH COLOSTOMY. ON (B)(6) 2004 THE PATIENT PRESENTED WITH BACK PAIN AND AN INCREASING HERNIA AND UNDERWENT SURGERY WHICH CONSISTED OF AN INCARCERATED INCISION HERNIA REPAIR WITH MESH. POST-OP IT WAS NOTED THAT THERE WAS SOME PAIN CONTROL DIFFICULTY. ON (B)(6) 2004 THE PATIENT WAS DISCHARGED FROM HOSPITAL. ON (B)(6) 2007 THE PATIENT PRESENTED WITH LEFT KNEE PAIN. THE PATIENT REPORTED RECEIVING AN INJURY TO THE LEFT KNEE TWO WEEKS PRIOR. REPORTEDLY, THE PATIENT HAD FALLEN STRIKING THE ANTERIOR ASPECT OF THE KNEE AND SINCE HAD HAD ACHING PAIN AND OCCASIONAL POPPING, CRACKING, AND GIVING AWAY. X-RAYS SHOWED SOME VERY MINIMAL JOINT SPACE NARROWING AT THE PATELLOFEMORAL. ASSESSMENT: CHONDROMALACIA PATELLAE. ON (B)(6) 2007 THE PATIENT PRESENTED WITH CHRONIC NECK PAIN AND LUMBAR SPINE ISSUES. THE PATIENT¿S PAIN WAS PRIMARILY IN THE POSTERIOR CERVICAL REGIONS WITH SYMPTOMS IN BOTH SHOULDERS. THE PAIN WAS DESCRIBED AS CONSTANT IN NATURE AND INTERFERED WITH DAILY LIVING ACTIVITIES. PRIOR CERVICAL X-RAYS SHOWED MODERATE CERVICAL SPONDYLOLISTHESIS THROUGH THE ENTIRE SPINE MOST PREVALENT AT C5-6. A CERVICAL MRI SHOWED MODERATE TO SEVERE CERVICAL STENOSIS AT C4-5 AND C5-6 WITH MILD FLATTENING OF THE CORD. ASSESSMENT: CERVICAL ARTHRITIS. ON (B)(6) 2007 THE PATIENT UNDERWENT A CERVICAL MRI WHICH SHOWED MULTILEVEL DISC AND OSTEOPHYTE BEING MOST PRONOUNCED AT C5-6 WITH LEFTWARD ASYMMETRY ENCROACHMENT ON THE CANAL RIGHTWARD FORAMINAL ENCROACHMENT. BILATERAL FORAMINAL ENCROACHMENT WAS ALSO SEEN AT C4-5 AND WAS MORE PROMINENT RIGHTWARD WITH MORE ASYMMETRIC LEFTWARD ENCROACHMENT AT C3-4. ON (B)(6) 2007 THE PATIENT PRESENTED WITH KNOWN CERVICAL STENOSIS. PER THE ENCOUNTER NOTES THE PATIENT HAD UNDERGONE PHYSICAL THERAPY AND EPIDURAL INJECTIONS BUT STILL REMAINED SYMPTOMATIC REGARDING NECK AND RADICULAR SYMPTOMS IN THE UPPER EXTREMITIES. THE PATIENT PRESENTED FOR A SURGICAL CONSULTATION. ON (B)(6) 2007 THE PATIENT PRESENTED WITH CHRONIC BACK AND NECK PAIN. ON (B)(6) 2007 THE PATIENT PRESENTED WITH NECK PAIN AND THE PREOPERATIVE DIAGNOSIS OF SEVERE SPINAL STENOSIS C4-5 AND C5-6; THE PATIENT UNDERWENT SURGERY WHICH CONSISTED OF AN ANTERIOR CERVICAL DISCECTOMY; ANTERIOR CERVICAL FUSION C4-5 AND C5-6; PLACEMENT OF INTERBODY SPACER X 2; ANTERIOR INSTRUMENTATION, C4-C5-C6; AND AUTOGRAPH . PER THE OPERATIVE REPORT ¿¿.INTERBODY SPACER OF APPROPRIATE SIZE WITH INFUSE PLACED CENTRALLY WAS THEN PLACED IN THE C4-C5 INTERSPACE. DISTRACTION PINS WERE THEN MOVED TO C6. IDENTICAL PROCEDURE WAS PERFORMED AT C5-C6 WITH ANTERIOR ANNULOTOMY, COMPLETE DISCECTOMY, REMOVAL OF POSTERIOR OSTEOPHYTES WITH A HIGH-SPEED BURR, MICROCURETTE, PITUITARIES, AND SMALL HOOK UTILIZED TO COMPLETE THE POSTERIOR AND FORAMINAL DECOMPRESSION. ENDPLATES WERE ALSO PREPARED WITH A HIGH-SPEED BURR. INTERBODY SPACER WITH APPROPRIATE SIZE WITH INFUSE PLACED CENTRALLY. OF NOTE, THROUGHOUT THE PROCEDURE, THERE WERE MULTIPLE BOUTS OF COPIOUS IRRIGATIONS WITH STERILE SALINE, WITH SPACERS PLACED IN C4-C5 AND C5-C6, THE PLATE WAS THEN TRANSFIXED TO THE ANTERIOR CERVICAL SPINE. UNICORTICAL VARIABLE-ANGLED SCREWS WERE PLACED IN C4-C5-C6. THESE HAVE BEEN LOCKED TO THE PLATE. AP AND LATERAL RADIOGRAPHS WERE TAKEN AT THIS TIME TO CONFIRM APPROPRIATE PLACEMENT OF HARDWARE AND BONE GRAFT. NO PATIENT COMPLICATIONS WERE NOTED. ON (B)(6) 2007 THE PATIENT PRESENTED WITH IMPROVING UPPER EXTREMITY SYMPTOMS AND POSTERIOR NECK PAIN. ASSESSMENT: CERVICAL ARTHRITIS. ON (B)(6) 2008 THE PATIENT PRESENTED FOR A F/U AFTER CERVICAL SURGERY. THE PATIENT REPORTED RESIDUAL PAIN IN SHOULDERS AND LOWER BACK PAIN. THE PATIENT REPORTED HAVING ANXIETY ATTACKS. LABS WERE TAKE WHICH SHOWED AN ELEVATED A1C AND ABNORMAL MICROALBUMIN. ON (B)(6) 2008 THE PATIENT PRESENTED WITH IMPROVED PAIN AND NUMBNESS AND TINGLING IN THE BILATERAL UPPER EXTREMITIES. ON (B)(6) 2008 THE PATIENT PRESENT FOR A DIABETES AND HTN FOLLOW-UP. THE PATIENT HAD GAINED 11LBS SINCE THE LAST VISIT. THE PATIENT REPORTED IMPROVED NECK PAIN AND A LOT OF LOWER BACK PAIN. ON (B)(6) 2008 THE PATIENT PRESENTED WITH MILD NECK PAIN; AN OCCASIONAL FEELING OF NUMBNESS AND AN ELECTRICAL FEELING HANDS; LEFT THUMB PAIN WITH NUMBNESS; AND THE FEELING THAT THE LEFT HAND ¿LOCKS UP.¿ EMG AND VC STUDIES SHOWED MILD LEFT CTS AND MILD BASAL JOINT ARTHRITIS (LEFT HAND). ASSESSMENT: CARPAL TUNNEL SYNDROME AND HAND ARTHRITIS. THE PATIENT WAS PUT IN A LEFT THUMB SPLINT AND GIVEN NONSTEROIDALS. ON (B)(6) 2008 THE PATIENT PRESENTED WITH ¿A LOT¿ OF PAIN IN LOWER BACK AND PAIN IN NECK. THE PATIENT ALSO REPORTED FATIGUE, NASAL CONGESTION, JOINT PAIN, MOODINESS, AND ELEVATED BLOOD SUGARS. LABS WERE CONDUCTED WHICH SHOWED LOW VITAMIN D LEVELS. ON (B)(6) 2008 THE PATIENT PRESENTED WITH ACUTE DIZZINESS, BALANCE ISSUES AND WEAKNESS. THE PATIENT REPORTED THEIR VISION GOING BLACK AT TIMES. ON (B)(6) 2008 THE PATIENT PRESENTED DIZZINESS AND SEVERE BACK AND NECK PAIN. PER THE ENCOUNTER NOTES A RECENT MRI DID SHOW SOME CHRONIC WHITE MATTER. LABS WERE TAKEN WHICH SHOWED HIGH TRIGLYCERIDES. ON (B)(6) 2009 THE PATIENT COMPLAINED OF WORSENING DIZZINESS. THE PATIENT WAS ON A LARGE QUANTITY OF PSYCH MEDS AND THE PATIENT HAD BEEN TOLD THAT THIS WAS A LIKELY CONTRIBUTOR. THE PATIENT ALSO ADMITTED TO LUMBAR PAIN, JOINT PAIN, NUMBNESS, VERTIGO, MOODINESS, MYALGIAS, AND FATIGUE. ON (B)(6) 2009 THE PATIENT PRESENTED WITH A HISTORY OF NEAR SYNCOPE. THE PATIENT UNDERWENT A TEST WITH A 24 HOUR HOLTER MONITOR. CONCLUSION: POOR STUDY SUGGESTING SINUS RHYTHM WITH RARE PREMATURE ATRIAL CONTRACTIONS WITH FREQUENT PERIODS OF SINUS TACHYCARDIA. ON (B)(6) 2009 THE PATIENT PRESENTED WITH NEW ACUTE DERMATOLOGIC SYMPTOMS. THE PATIENT COMPLAINED OF WARTS ON THE LEFT HAND. ON (B)(6) 2009 THE PATIENT PRESENTED WITH IMPROVED RIGHT RIB PAIN AND IMPROVED DIZZINESS. THE PATIENT ALSO ADMITTED TO CONGESTION, LUMBAR PAIN, JOINT PAIN, NUMBNESS, VERTIGO, MOODINESS, MYALGIAS, AND FATIGUE. ON (B)(6) 2009 THE PATIENT REPORTED ELEVATED GLUCOSE, DIZZINESS, LUMBAR AND NECK PAIN. ASSESSMENT: HYPERLIPIDEMIA, DIZZINESS, AND DIABETES. LABS SHOWED ELEVATED TG AND IMPROVING VIT D. ON (B)(6) 2009 THE PATIENT PRESENTED WITH AN ADENOMATOUS POLYP AND UNDERWENT SURGICAL REMOVAL. ON (B)(6) 2009 THE PATIENT COMPLAINED OF A LOT OF PAIN IN THE NECK AND LUMBAR SPINE AND BURNING IN LEGS WITH ACTIVITY. THE PATIENT ALSO REPORTED HIGH GLUCOSE. ON (B)(6) 2009 THE PATIENT PRESENTED WITH DIARRHEA AND RECTAL BLEEDING. THE PATIENT UNDERWENT A COLONOSCOPY AND HOT BIOPSY PROCEDURE WHICH SHOWED MULTIPLE COLON POLYPS. SEVEN POLYPS WERE REMOVED IN THE COLON AND A SESSILE POLYP IN THE RECTUM WAS THOROUGHLY CAUTERIZED. NO DIVERTICULUM WAS PRESENT. NO PATIENT COMPLICATIONS WERE REPORTED. ON (B)(6) 2009 THE PATIENT REPORTED LUMBAR AND NECK PAIN, JOINT PAIN, MYALGIAS, MOODINESS, FATIGUE, AND ELEVATED BLOOD SUGARS. THE PATIENT UNDERWENT LABS WHICH SHOWED VERY ELEVATED TG ON (B)(6) 2009 HE PATIENT PRESENTED WITH OCCASIONAL COUGH AND PAIN IN UPPER ABDOMEN. IT WAS REPORTED THAT THE PATIENT WAS WEANING OFF OF AMITRIPTYLINE AND SEROQUEL. THE PATIENT ALSO REPORTED LUMBAR AND NECK PAIN, JOINT PAIN, MYALGIAS, MOODINESS, FATIGUE, AND ELEVATED BLOOD SUGARS. ON (B)(6) 2010 THE PATIENT PRESENTED WITH PERSISTENT COUGH, CHEST CONGESTION, AND SHORTNESS OF BREATH. DIAGNOSIS: ACUTE BRONCHITIS. THE PATIENT ALSO REPORTED NECK AND LUMBAR PAIN. ON (B)(6) 2010 THE PATIENT COMPLAINED THAT THEY DID NOT FEEL WELL AND HAD BEEN SICK WITH FLU LIKE SYMPTOMS FOR SEVERAL WEEKS. THE PATIENT HAD LOST SOME WEIGHT. THE PATIENT ALSO REPORTED BACK AND NECK PAIN. THE PATIENT UNDERWENT LABS WHICH SHOWED VERY ELEVATED LIPIDS. ON (B)(6) 2010 THE PATIENT UNDERWENT A BONE DENSITY SCAN WHICH SHOWED OSTEOPENIA. ON (B)(6) 2010 THE PATIENT PRESENTED WITH PERSISTENT CONGESTION AND COUGHING. THE PATIENT ALSO REPORTED ¿A LOT OF NECK PAIN.¿ THE PATIENT ALSO HAD A SLIGHTLY ELEVATED OF SERUM CALCIUM, GLUCOSE, AND TRIGLYCERIDES. ON (B)(6) 2010 THE PATIENT UNDERWENT CHEST X-RAYS WHICH SHOWED NO ACUTE PROCESS. ON (B)(6) 2010 THE PATIENT PRESENTED WITH NECK PAIN AND REPORTED THEY NEEDED NARCOTICS FOR THE PAIN. THE PATIENT WAS INFORMED THAT THE OPERATIVE LEVEL APPEARED WELL FUSED THEREFORE THE PAIN WOULD NOT HAVE EMANATED FROM A SOLIDLY HEALED LEVEL AND THEY WOULD EVALUATE ADJACENT SEGMENT DISEASE. ON (B)(6) 2010 THE PATIENT PRESENTED 2 YEARS POST ANTERIOR CERVICAL FUSION COMPLAINING OF POSTERIOR AXIAL TYPE OF NECK PAIN. ASSESSMENT: CERVICAL ARTHRITIS; CERVICAL SPINE DDD; AND CERVICALGIA. THE PATIENT WAS INFORMED THAT ¿THERE IS NO SURGICAL OPTION FOR THEIR CURRENT COMPLAINTS.¿ ON (B)(6) 2010 THE PATIENT PRESENTED WITH PAIN AND UNDERWENT A MR C-SPINE WHICH DEMONSTRATED MILD DEGENERATIVE DISC AND JOINT DISEASE WITH MILD EFFACEMENT OF THE ANTERIOR THECAL SAC ON THE LEFT NOTED. ON (B)(6) 2010 THE PATIENT COMPLAINED OF NOT SLEEPING WELL, FATIGUE, ELEVATED GLUCOSE, POLYURIA, PERSISTENT COUGH, VITAMIN D DEFICIENCY, LUMBAR AND NECK PAIN. THE PATIENT UNDERWENT LABS WHICH SHOWED HIGH TRIGLYCERIDE, LOW HDL, HIGH CHOLESTEROL, AND HIGH VLDL. ON (B)(6) 2010, IT WAS REPORTED THAT THE PATIENT WAS HOSPITALIZED WITH CHEST DISCOMFORT. THE PATIENT PRESENTED LEFT SIDE CHEST PAIN WITH RADIATION INTO JAW AND LEFT HAND. MYOCARDIAL INFARCTION WAS RULED OUT. ON (B)(6) 2010 THE PATIENT UNDERWENT A SLEEP STUDY THAT SHOWED CLINICALLY SIGNIFICANT REM RELATED TO OBSTRUCTIVE SLEEP APNEA WITH OXYGEN DESATURATIONS. ON (B)(6) 2010 THE PATIENT PRESENTED WITH CHEST PAIN AND DIABETES. THE PATIENT UNDERWENT A CARDIAC SPECT IMAGING WHICH SHOWED NO EVIDENCE OF SIGNIFICANT ISCHEMIA, NORMAL LV FUNCTION, AND A LOW PROBABILITY OF OCCLUSIVE CORONARY DISEASE. ON (B)(6) 2010 THE PATIENT PRESENTED PERSISTENT CHEST CONGESTION, COUGH, AND SHORTNESS OF BREATH. ON (B)(6) 2010 THE PATIENT PRESENTED WITH INTERMITTENT CLAUDICATION AND UNDERWENT A LOWER EXTREMITY ARTERIAL STUDY WHICH WAS NORMAL WITH NO EVIDENCE OF PERIPHERAL VASCULAR OCCLUSIVE DISEASE. THE PATIENT UNDERWENT A CHEST X-RAY WHICH SHOWED A VAGUE DENSITY PROJECTING OVER THE ANTERIOR RIGHT FIFTH RIB MEASURING APPROX. 2CM. ON (B)(6) 2010 THE PATIENT PRESENTED SOME PERSISTENT CLAUDICATION AND IMPROVED COUGH. THE PATIENT DID HAVE A SHADOW ON A CHEST X-RAY. ON (B)(6)2010 THE PATIENT PRESENTED WITH A HISTORY OF DENSITY RIGHT FIFTH RIB AND UNDERWENT A CT OF THE CHEST WHICH DEMONSTRATED LOW GRADE ATELECTASIS OR SCARRING IN THE RIGHT MIDDLE LOBE. ON (B)(6) 2010 THE PATIENT PRESENTED FOR A SLEEP STUDY. THE PATIENT LEFT THE STUDY EARLY AND DID NOT MEET THE 180 MINUTE CRITERIA. ON (B)(6) 2010 THE PATIENT UNDERWENT A SLEEP STUDY (ALL NIGHT POLYSOMNOGRAPHY). THE PATIENT UNDERWENT AN EXCELLENT CPAP TITRATION FOR OSA. PER THE ENCOUNTER NOTES THE PATIENTS ELEVATED REM LATENCY AND DECREASED REM SLEEP MAY HAVE BEEN RELATED TO SSRI USE. ON (B)(6) 2010 THE PATIENT PRESENTED IMPROVED SYMPTOMS. IT WAS REPORTED THAT THE PATIENT HAD BEGUN CPAP AFTER HAVING UNDERGONE A SLEEP STUDY. THE PATIENT REPORTED A LOT OF REFLUX. ON (B)(6) 2010 THE PATIENT PRESENTED WITH RECURRENT CHEST TIGHTNESS AND COUGH WITH THICK SPUTUM. THE PATIENT REPORTED THEY OMEPRAZOLE WAS NOT REALLY WORKING. THE PATIENT ALSO REPORTED CUTTING BACK ON CIGARETTES. THE PATIENT ALSO REPORTED LUMBAR AND NECK PAIN, JOINT PAIN, MYALGIAS, MOODINESS, FATIGUE, AND ELEVATED BLOOD SUGARS. ON (B)(6) 2011 THE PATIENT UNDERWENT LABS WHICH DEMONSTRATED LOW HDL, HIGH TRIGLYCERIDES, AND HIGH VLDL. ON (B)(6) 2011 THE PATIENT COMPLAINED OF ¿FEELING AWFUL¿ AND PRESENTED A LOT OF CONGESTION. THE PATIENT ALSO ADMITTED TO FATIGUE, CHEST PAIN, LUMBAR BACK PAIN, NECK PAIN, JOINT PAIN, MYALGIAS, ND MOODINESS. THE PATIENT ADMITTED TO ELEVATED BLOOD SUGARS. ON (B)(6) 2011 THE PATIENT PRESENTED UPPER RESPIRATORY SYMPTOMS AND UNDERWENT LABS WHICH DEMONSTRATED HIGH TRIGLYCERIDE, HIGH CHOLESTEROL, LOW CREATINE, LOW HDL, HIGH LDL, AND HIGH VLDL. ON (B)(6) 2011 THE PATENT PRESENTED WITH THE FEELING OF BEING OFF BALANCE WHEN WALKING; FEELING LIKE THEY WERE GOING TO PASS OUT; AND PERSISTENT NECK PAIN. THE PATIENT ALSO ADMITTED TO LUMBAR PAIN, JOINT PAIN, NUMBNESS, VERTIGO, MOODINESS, MYALGIAS, AND FATIGUE. ON (B)(6) 2011 THE PATIENT PRESENTED WITH REFLUX. THE PATIENT ALSO REPORTED THEY WERE UNABLE TO USE THEIR CPAP AS IT DID NOT FIT CORRECTLY. LABS WERE TAKEN WHICH DEMONSTRATED HIGH TRIGLYCERIDE AND LOW HDL. THE PATIENT ALSO UNDERWENT A EKG WHICH SHOWED A BORDERLINE FIRST DEGREE AV BLOCK AND RIGHT AXIS DEVIATION: ABNORMAL EKG. ON (B)(6) 2011 THE PATIENT PRESENTED WITH STRESS; INCREASED MEMORY CHANGES; CRAMPS IN ARMS AND LEGS; BACK AND NECK PAIN. THE PATIENT REPORTED A RECENT SUB-CONJUNCTIONAL HEMORRHAGE IN THE INNER AREA OF LEFT EYE. ON (B)(6) 2012 THE PATIENT PRESENTED DEPRESSION; NERVOUS STOMACH; PAIN IN CHEST; FATIGUE; PAIN IN NECK AND BACK. THE PATIENT WAS INTERESTED IN QUITTING SMOKING. ON (B)(6) 2012 THE PATIENT PRESENTED WITH TINGLING IN RIGHT HAND AND FINGER TIPS AND OCCASIONALLY IN THE LEFT HAND. THE PATIENT ALSO REPORTED OCCASIONAL SHARP PAINS IN HEAD. DIAGNOSIS: CERVICALGIA AND POLYNEUROPATHY IN DIABETES. ON (B)(6) 2012 THE PATIENT COMPLAINED OF NUMBNESS AND TINGLING ALL OVER; NECK PAIN; ARM WEAKNESS; FREQUENTLY DROPPING THINGS; FREQUENTLY FALLING; FATIGUE AND SLEEP DISTURBANCES. THE PATIENT REPORTED THEY COULD NOT COMPLETE A SCHEDULED NSM TESTING DUE TO PAIN. ON (B)(6) 2012 THE PATIENT PRESENTED WITH PAIN AND UNDERWENT A MRI OF THE CERVICAL SPINE WHICH SHOWED STABLE POST OPERATIVE CHANGES IN COMPARISON OF (B)(6) 2010 EXAM. ON (B)(6) 2012 THE PATIENT PRESENTED CONCERNS OVER TREMORS IN HANDS; NUMBNESS IN FINGERS OF BOTH HANDS; A BURNING SENSATION IN FEET; AND DIFFICULTY SLEEPING. THE PATIENT WONDERED IF THEY HAD GOUT. LABS WERE TAKEN WHICH WERE ESSENTIALLY FINE WITH THE EXCEPTION OF TRIGLYCERIDE WHICH WAS HIGH. THE PATIENT UNDERWENT A ECG WHICH WAS WITHOUT SIGNIFICANT ABNORMALITIES. ON (B)(6) 2013 THE PATIENT COMPLAINED OF THEIR TOES GOING NUMB, BODY ACHES, BACK AND NECK PAIN. THE PATIENT, REPORTEDLY, HAD NOT TAKEN PAIN MEDICATION SIN THE (B)(6). THE PATIENT UNDERWENT A NEUROPATHY SCREENING SCORING. THE PATIENT APPEARED MILDLY AGITATED. ON (B)(6) 2013 THE PATIENT PRESENTED WITH SHARP PAINS IN THEIR HEAD, STRESS, CHEST PAIN, AND PAIN IN NECK, LOWER BACK, SHOULDERS, AND FEET. THE PATIENT ALSO COMPLAINED OF FATIGUE AND MUSCLE WEAKNESS. THE PATIENT UNDERWENT A ECG WHICH SHOWED SINUS TACHYCARDIA, FIRST DEGREE AV BLOCK AND LEFT AXIS DEVIATION CONSISTENT WITH LAFB. THE ECG WAS WITHOUT SIGNIFICANT ABNORMALITIES. THE PATIENT UNDERWENT LABS WHICH DEMONSTRATED ELEVATED HGB, VLDL, GLUCOSE, AST, ABSOLUTE MONOCYTE, ABSOLUTE NEUTROPHIL, RWD-SD, AND TRIGLYCERIDE. THE PATIENT HAD LOW MAGNESIUM, HDL, AND TESTOSTERONE. IN THE ENCOUNTER NOTES IT STATED THAT THE PATIENT NEEDED TO BE ON A STRICT DIABETIC DIET. ON (B)(6) 2013 THE PATIENT UNDERWENT A LUMBAR SPINE MRI WHICH DEMONSTRATED A L4-5 CONCENTRIC DISC BULGE AND A MILD AMOUNT OF NEURAL FORAMINAL NARROWING RIGHT SUSPECTED TO BE SLIGHTLY GREATER THAN THE LEFT AND LS- SI BULGE WITH SLIGHT RIGHT NEURAL FORAMINAL NARROWING GREATER THAN LEFT. NO ASYMMETRIC HERNIATION OR ACUTE BONY ABNORMALITY OR SUSPICIOUS ENHANCING LESIONS WERE NOTED. A MR C-SPINE WAS TAKEN WHICH SHOWED ANTERIOR CERVICAL FUSION CHANGES FROM C4 THROUGH C6 WITH LEFT C3-4 NEURAL FORAMINAL NARROWING AND SLIGHT BONY PROTRUSION ALONG THE INFERIOR ASPECT OF C5 DEFORMING THE ANTERIOR LEFT THECAL SAC; C6- 7 BULGE WITH SLIGHT AMOUNT OF ASYMMETRY JUST TO THE TIGHT OF MIDLINE; AND SLIGHT LEFT NEURAL FORAMINAL NARROWING AT THAT LEVEL ALSO NOTED DUE TO OSTEOPHYTES. ON (B)(6) 2013 THE PATIENT PRESENTED WITH CERVICAL AND LUMBAR PAIN. THE PATIENT REPORTED THAT THEY HAD THE CERVICAL PAIN STARTING TWO WEEK AFTER THEIR 2007 ACDF C4-6 SURGERY. CERVICAL X-RAYS REVEALED BONE GRAFTS AND HARDWARE IN GOOD POSITION WITHOUT EVIDENCE OF LOOSENING. THERE APPEARED TO BE A BONEY FUSION ALONG THE POSTERIOR ASPECT OF THE VERTEBRAE, HOWEVER INCORPORATION OF THE BONE GRAFT HAD NOT BEEN ACCOMPLISHED. ON (B)(6) 2013 THE PATIENT PRESENTED FOR A DIABETESF/U. THE PATIENT WAS MONITORING THEIR GLUCOSE DAILY. IN THE ENCOUNTER NOTES IT STATED THAT THE PATIENT DID HAVE AN ABNORMAL MICROALBUMIM IN (B)(6). THE PATIENT COMPLAINED OF A PAIN IN NECK, SHOULDERS, LOWER BACK AND FEET; A SORE ON THE LEFT CALF THAT WOULD NOT HEAL; WEAKNESS; AND FATIGUE. THE PATIENT WAS NOT USING THEIR CPAP ¿ AS THEY SAID IT DID NOT FIT RIGHT. THE PATIENT HAD LOW TESTOSTERONE AND LOW MAGNESIUM LEVELS. ON (B)(6) 2007 AND (B)(6) 2012 THE PATIENT PRESENTED WITH CHRONIC UNRELENTING BACK PAIN; MODERATE LEFT LEG PAIN; AND OCCASIONAL RADICULAR TYPE OF PAIN INTO THE RIGHT LEG. PREVIOUS RADIOGRAPHS HAD SHOWED: LUMBAR X-RAY -BONE GRAFT AND HARDWARE IN EXCELLENT POSITIONS; CERVICAL SPINE MRI - MODERATE DISC SPACE NARROWING AT V6-7 WITH MILD STENOSIS; AND A THORACIC MRI - ADVANCED DISC DESICCATION AT L5-S1 WITH DISC SPACE COLLAPSE FROM THE BASE TO PROTRUSION PRODUCING MODERATE FORAMINAL STENOSIS; MILD DESICCATION AT L4-5 WITH MILD BROAD BASED BULGE. THE PATIENT WAS PRESCRIBED DILAUDID AND ULTRAM. THE PATIENT EXPRESSED THAT THEY WOULD LIKE TO MOVE FORWARD WITH SURGICAL INTERVENTION. ON (B)(6) 2013 THE PATIENT PRESENTED WITH PAIN AND THE PREOPERATIVE DIAGNOSIS OF SPINAL STENOSIS A L5-S1 AND DEGENERATIVE DISC DISEASE L5-S1. THE PATIENT UNDERWENT SURGERY WHICH CONSISTED OF A RIGHT SIDED L5-S1 TRANS-FACET DECOMPRESSION; L5-S1 LATERAL FUSION; L5-S1 POSTERIOR LUMBAR INTERBODY FUSION; PLACEMENT OF MACHINED INTERBODY SPACER X1; POSTERIOR INSTRUMENTATION L5-S1; AND AUTOLOGOUS BONE GRAFT. THE PATIENT WAS MONITORED CONTINUOUSLY DURING SURGERY WITH SSEP AND EMG. PER THE OPERATIVE REPORT ¿¿AT THIS POINT THE INTERSPACE WAS THEN SIZED. NEXT A PORTAL WAS USED TO PACK AUTOLOGOUS BONE IN THE ANTERIOR DISC SPACE INCLUDING PLACEMENT INFUSE ANTERIORLY. NEXT A 10MM MACHINED INTERBODY SPACER WITH INFUSE PLACED CENTRALLY WAS THEN PLACED IN THE INTERSPACE. AFTER CONFIRMING ITS POSITION FLUOROSCOPICALLY IT WAS THEN ROTATED INTO THE TRANSVERSE PLANE. NEXT ADDITIONAL AUTOLOGOUS BONE GRAFT WAS PLACED POSTERIOR TO THE INTERBODY SPACER. METICULOUS HEMOSTASIS WAS OBTAINED. FLUOROSCOPY WAS UTILIZED TO CONFIRM APPROPRIATE POSITION. A BALL-TIPPED PROBE WAS UTILIZED TO INSPECT THE EXITING AND TRAVERSING ROOTS AND ENSURE THAT THEY WERE FREE OF ANY PRESSURE. NEXT UNDER LOUPE VISUALIZATION A 3D-GAUGE SPINAL NEEDLE WAS UTILIZED TO INJECT 0.25 MEG OF MORPHINE INTRATHECALLY. DURASEAL WAS THEN PLACED OVER THE THECAL SAC TO PREVENT MIGRATION OF THE BONE GRAFT. ADDITIONAL BONE GRAFT WAS THEN PLACED POSTEROLATERALLV IN CONTACT WITH THE REMAINDER OF THE FACET AND TRANSVERSE PROCESS THUS PERFORMING A POSTERIOR LATERAL FUSION¿.¿ NO PATIENT COMPLICATIONS WERE NOTED. ON (B)(6) 2013 THE PATIENT WAS DISCHARGED FROM HOSPITAL. ON (B)(6) 2013 THE PATIENT PRESENTED WITH FOR A POST OP F/U. THE PATIENT REPORTED HAVING RECENTLY BEEN HOSPITALIZED FOR ¿MEDICAL ISSUES¿. THE PATIENT HAD MODERATE BACK PAIN WITH OCCASIONAL RADICULAR TYPE OF PAIN INTO THE RIGHT LEG. ON (B)(6) 2013 THE PATIENT PRESENTED FOR A HOSPITAL F/U . IT WAS REPORTED THAT THE PATIENT HAD STARTED TAKING SEROQUEL AGAIN TO SLEEP AGAINST ADVICE DUE TO POSSIBLE NEUROLEPTIC MALIGNANT SYNDROME (NMS). ASSESSMENT: ALTERED MENTAL STATUS; RHABDOMYOLYSIS; POLYNEUROPATHY IN DIABETES; TESTICULAR HYPOFUNCTION; HYPERLIPIDEMIA; AND SPINAL STENOSIS OF THE LUMBAR REGION. THE PATIENT UNDERWENT A SERIES OF LABS: THE PATIENT HAD A HIGH POTASSIUM AND RWD AND A LOW RED BLOOD CELL COUNT, HEMOGLOBIN, AND HEMOCRIT. ON (B)(6) 2013 THE PATIENT UNDERWENT A CHEST X-RAY WHICH SHOWED SIGNIFICANT IMPROVEMENT IN AERATION IN THE RIGHT UPPER LOBE. NO NEW CONSOLIDATION OF EFFUSION OR EDEMA. ON (B)(6) 2013 THE PATIENT UNDERWENT A CHEST X-RAY WHICH SHOWED MARKED IMPROVEMENT IN THE RIGHT PERIHILAR CONSOLIDATION AND EFFUSION. ON (B)(6) 2013 THE PATIENT UNDERWENT X-RAYS THAT DEMONSTRATED SUCCESSFUL INTUBATIONS AND PATCHY INFILTRATE RIGHT BASE. ON (B)(6) 2013 THE PATIENT UNDERWENT A CHEST X-RAY WHICH SHOWED DECREASE ALTHOUGH MILDLY PERSISTENT RIGHT MID TO BASILAR ATELECTASIS AND/OR INFILTRATE. ON (B)(6) 2013 THE PATIENT UNDERWENT A CHEST X-RAY WHICH SHOWED NO SIGNIFICANT INTERVAL CHANGE. ON (B)(6) 2013 THE PATIENT UNDERWENT CHEST X-RAYS WHICH SHOWED NO CHANGES. ON (B)(6) 2013 THE PATIENT WAS SUCCESSFULLY EXTUBATED. ON (B)(6) 2013 THE PATIENT UNDERWENT CHEST X-RAYS WHICH SHOWED NO ACUTE PROCESS. ON (B)(6) 2006 THE PATIENT PRESENTED FOR A F/U AFTER A HOSPITAL STAY. IT WAS REPORTED THAT THE PATIENT HAD STARTED SMOKING AGAIN. THE PATIENT HAD BEEN DOCUMENTED AS HAVING THE RECENT DIAGNOSIS OF PNEUMONIA RESOLVED. THE PATIENT COMPLAINED OF LOWER BACK PAIN, FATIGUE, DECREASED LIBIDO, MUSCLE ACHES, WEAKNESS AND SLEEP DISTURBANCE. ASSESSMENTS: ALTERED MENTAL STATUS; ESSENTIAL HYPERTENSION; TESTICULAR HYPOFUNCTION; AND DIABETES MELLITUS. PER THE ENCOUNTER NOTES THE PATIENT HAD BEEN DISCHARGED FROM THE PRACTICE DUE TO SIGNING OUT OF THE HOSPITAL AGAINST MEDICAL ADVICE (AMA). ON (B)(6) 2013 THE PATIENT PRESENTED WITH WEAKNESS AND FALLS POST LUMBAR FUSION. THE PATIENT UNDERWENT A CT OF THE LUMBAR SPINE WHICH SHOWED LOWER LUMBAR DEGENERATIVE AND POSTOPERATIVE CHANGES WITH NO DEFINITE CT EVIDENCE OF COMPLICATION. A SLIGHTLY GREATER AMOUNT OF BONY POSTOPERATIVE CHANGE TOWARDS THE RIGHT NEURAL FORAMEN EVIDENT AT L5-S1 BUT THE EXITING NERVE ROOT APPEARS TO EXIT WITHOUT SIGNIFICANT IMPINGEMENT. IT SHOULD BE NOTED THAT: L4-5 DEMONSTRATED VACUUM PHENOMENON WITHIN THE DISC AND CONCENTRIC DISC BULGE AND A COMPONENT OF LIGAMENTOUS HYPERTROPHY. ON (B)(6) 2013 THE PATIENT PRESENTED WITH MODERATE BACK PAIN. PER THE ENCOUNTER NOTES LUMBAR X-RAYS SHOWED BONE GRAFT AND HARDWARE IN EXCELLENT POSITION AND EARLY BONE CONSOLIDATION. A CERVICAL MRI DEMONSTRATED MODERATE DISC SPACE NARROWING AT C6-7 WITH MILD STENOSIS. A THORACIC MRI SHOWED ADVANCED DISC DESICCATION AT L5-S1 WITH DISC SPACE COLLAPSE FROM THE BASE TO PROTRUSION PRODUCING MODERATE FORAMINAL STENOSIS; MILD DESICCATION AT L4-5 WITH MILD BROAD BASED BULGE. ASSESSMENT: LUMBAR DEGENERATIVE DISC DISEASE; CERVICAL SPONDYLOLISTHESIS; CERVICAL DISPLACEMENT AND LUMBAR STENOSIS.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 394005 | INFUSE BONE GRAFT | FILLER, RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN, COLLAGEN SCAFFOLD WITH MET | NEK | MEDTRONIC SOFAMOR DANEK USA, INC | NA | M110701AAM |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | Other |