Cervicobrachial Syndrome Case Studies

DOI: 1/19/2006. The patient is a 59 -year-old male housekeeping aide who sustained a work-related injury to his neck, head and low back when the elevator he was riding suddenly drops causing him to fall backwards. The patient was subsequently diagnosed with status post cervical spine fusion; chronic pain syndrome; radiculopathy, cervical region; spinal stenosis, cervical region; and cervicobrachial syndrome. According to OMNI notes, the patient had cervical discectomy and fusion, lumbar strain and degenerative disc disease of the spine. As per visit notes on 4/7/16, the patient states that the medications have been helpful and effective for him for up to 40%. Cervical spine examination reveals a well-healed surgical scar posteriorly from the …show more content…
Adson’s test is positive bilaterally. The patient’s gait is antalgic on the right. She has 3+/5 strength on left shoulder abduction, left shoulder forward flexion, bilateral elbow flexion, left grip, right hip flexion and right knee extension. The patient’s motor strength is 4-/5 on right shoulder abduction, right shoulder forward flexion, right grip, left hip flexion and left knee extension. As per office notes dated 6/2/16, the patient complains of pain and discomfort located over his neck. The pain radiates towards the neck, upper and low back area, including the shoulders area going to forearms to fingers. He describes it as aching feeling, stinging, and throbbing pain. According to the patient, symptoms are constant (75-100%). The patient rates his pain as 10 when he is twisting and bending his head and neck on a consistent basis. He feels worse with bending at the head and neck, lifting, pulling, pushing, reaching, and twisting of the head and neck. Medication has been 70-80% helpful and effective in reducing pain. TheTranscutaneous electrical nerve stimulation (TENS) unit has not been as helpful or as effective for