Author: Alexander Dydyk, MA,DO
Co Author #1: John Kearney MD
Co Author #2: Amanda Rapp MBA MD

Patient Presentation:
A 72 year old female presented for evaluation of chronic low back and hip pain. She had a prior history of multiple failed spinal surgeries treated with lumbar epidural corticosteroid injections, and bilateral sacroiliac joint injections. Her pain was 10/10 on the VAS in intensity, was sharp in quality, constant, and radiated down her lateral thighs. It was worse in the left leg compared to the right. The pain interrupted her during sleep, and was worsened with walking. She ambulated with a walker due to pain and gait disorder, and had recently suffered a fall resulting in left elbow fracture. She was prescribed 15 milligram extended release morphine every 4 hours for the pain without significant relief.

History:
Past Medical History: lumbar multilevel degenerative spondylosis with severe L2-3 central canal stenosis; cervical spondylosis with myelopathy s/p C3-C6 fusion; osteoporosis; mood disorder with bipolar disorder and depression.
Past Surgical History: lumbar laminectomy 50 years prior; L3-S1 fusion 20 years prior; cervical fusion C3-C6 as above.
Total hip arthroplasty bilaterally;
Medications: morphine, alendronate, zolpidem, sertraline, sumatriptan;
Allergies: flexeril, cymbalta
Social History: married, retired, denies tobacco or recreational drug use. No current alcohol use.
Family History: Mother--diabetes and hypertension. Father--alcohol abuse

Physical Exam:
Vitals:
BMI 27.9, Heart Rate 95, Blood Pressure 146/92, Respiration Rate 16
General Exam:
Ambulating with four wheel walker. Severe antalgic gait with shortened swing phase on left; gait stable with assistance device.
Cardiovascular Exam:
Regular rate and rhythm, normal S1, S2, no clicks murmurs or rubs. Trace non pitting edema, left leg greater than right. Dorsalis pedis and posterior tibial pulses +2 bilaterally.
Respiratory Exam:
Clear to auscultation bilaterally, fair air movement, no crackles or wheezing
Abdominal Exam:
Soft non-tender to palpation, normal bowel sounds.
Musculoskeletal Exam:
Limited lumbar spine range of motion secondary to pain. Tenderness to palpation over bilateral lower lumbar paraspinal muscles and bilateral PSIS. Tenderness to palpation over left greater trochanter. Pain at greater trochanter elicited upon hip flexion. Lower extremity muscle strength 5/5 except for left hip flexor 3/5 and left hip abductor 3/5.
Special Tests:
Straight leg raise negative bilaterally. Trendelenburg positive on left.
Neurological Exam:
Diminished sensation in S1-S2 dermatomes on the left.
Deep Tendon Reflex symmetric L4, S1, bilaterally
Heel and toe walk unable to complete due to pain

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