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Medical Consultant Report and Summary
Case No: MD Physician: M.D.
Date: December 4, 2008 Medical Consultant: M.D.
1. Detailed (Chronological) Analysis: On February 14, 2002, the patient,
age 23, was working for assigned to the company where he was
lifting pallets when, according to a handwritten note dictated by the patient to , “I
felt a little pain in my right groin area…I noticed that my right testicle was larger than usual. Also
I had pain from the right front groin to the back of my right hip.”
The patient was apparently seen by a family physician, D.O., who ordered an
MRI scan of the lumbar spine. The report of this study, performed on May 2, 2002, was, “Normal
lumbar spine MRI.” The patient had chiropractic manipulations by , D.C. with
the last visit on August 19, 2002. After seeing another physician, Dr. (no further
information available), the patient next saw M.D., an Orthopaedic Surgeon, on
January 22, 2003.
Dr. reviewed the patient’s lumbar spine plain films and MRI scan and agreed with the
radiologist’s reading of normal MRI. He had the patient get a new MRI scan of the lumbar spine
at a different facility. This study, on February 11, 2003, showed “…subtle/minimal annular disc
bulging laterally on the right at L4-5 and L5-S1 which approaches the right lateral L4 and L5
nerve roots respectively. There is no focal disc protrusion, central canal stenosis, or significant
neural foramen stenosis at any level.”
Dr. performed a lumbar discogram on September 26, 2003. In the Operative Report,
he described the study as showing, “trace degeneration” at L4 and “central degeneration with
posterior leakage into the epidural space…” at L5. On October 8, 2003, Dr. noted that,
“The discogram did not find a surgical lesion.” The patient still complained of pain radiating to
the testicle; a urologist had seen the patient for that problem. Dr. referred the patient to
a Dr. for physical therapy.
The patient then saw M.D., an internist, who referred him to
M.D., a specialist in Rehabilitation Medicine, who examined him on April 20, 2004. Dr.
physical examination was most instructive: he noted:
“Light axial compression on the vertex of the skull produced low back pain.”
“SLR [Straight Leg Raising] at 45 degrees in the supine position produced low back pain but
double-leg sitting SLR with the patient’s ability to lean forward and touch his knees produced no
grimacing or discomfort from the patient. In the supine position with SLR, the patient did indicate
pain, both by grimacing, groaning, and indicating it was painful.”
The patient had “give-way” weakness throughout both lower extremities. He also had symmetric,
normal reflexes at the knees and ankles with intact sensation throughout both legs.
Dr. performed Electromyograms and Nerve Conduction Tests (EMGs and NCTs) on the
patient’s back and both legs on May 14, 2004. These studies were normal, with Dr. noting
that there were “No electrodiagnostic signs of a left or right lower extremity radiculopathy.”
In 2008, the patient was evaluated at The CORE Institute (Center for Orthopedic Research and
Education). The evaluation included physical examinations, x-rays, and other studies. I have
reviewed the x-ray films of the lumbar and sacral spine.
2. Proposed Standard(s) of Care: A patient with complaints of low back pain should have a
history, physical examination, x-rays, and, if indicated, diagnostic studies such as CAT scan or
MRI scan. Not all patients with low back pain , however, require diagnostic studies.