At a Glance
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Case
Marcus Thompson · MR-2023-04412
MVA rear-end (~35 mph) · 02/03/2023
MVA rear-end (~35 mph) · 02/03/2023
Main Issue
L4-L5 disc herniation with left L5 radiculopathy
Care Path
ED→
MRI→
Ortho→
PT→
LESI→
Follow-up MRI→
CT Surgical Planning
Last Major Event
CT lumbar surgical planning · Nov 14, 2023
Methodist Medical Center · Dr. James Wu, MD
Methodist Medical Center · Dr. James Wu, MD
File Status
7 of 7 visits filed · 4 imaging studies · 3 providers
Records sorted oldest to newest
Records sorted oldest to newest
Visit Summary
One row per encounter — quick reference across the full case
| Date | Days Post-Injury | Clinic | Provider | Diagnosis / Finding | Treatment Plan | Imaging |
|---|---|---|---|---|---|---|
| 02/03/2023 | Day 0 | Methodist Medical Center | Dr. Sarah Kline, MD | Acute lumbar strain; rule out disc injury | IV ketorolac, diazepam, naproxen 500mg BID, muscle relaxer | X-Ray: No fracture |
| 02/14/2023 | Day 11 | Advanced Imaging — FW | Dr. Kevin Marsh, MD | L4-L5 disc herniation; left L5 nerve root contact | MRI diagnostic study — no treatment this visit | MRI: L4-L5 herniation 8mm |
| 02/22/2023 | Day 19 | Texas Spine & Orthopedic | Dr. Ramon Castillo, MD | L4-L5 disc herniation w/ left L5 radiculopathy | PT 3x/wk × 8wk; LESI recommended; gabapentin 300mg TID | — |
| 03/01/2023 | Day 26 | Peak Performance PT | Sarah Nguyen, DPT | Lumbar radiculopathy; ODI 62% (severe) | McKenzie protocol, traction, TENS, core stabilization | — |
| 04/18/2023 | Day 74 | Texas Spine & Orthopedic | Dr. Ramon Castillo, MD | L4-L5 radiculopathy — insufficient conservative response | L4-L5 transforaminal LESI left (dexamethasone + bupivacaine) | Fluoro guidance |
| 08/09/2023 | Day 187 | Advanced Imaging — FW | Dr. Kevin Marsh, MD | Persistent L4-L5 herniation; progressive DDD; new facet arthropathy | Follow-up MRI — no change in herniation size; surgical consult initiated | MRI: Unchanged 8mm + DDD progression |
| 11/14/2023 | Day 284 | Methodist Medical Center | Dr. James Wu, MD | Ossified disc herniation; moderate-severe lateral recess stenosis | CT surgical planning; pedicle morphology assessed; fusion candidacy confirmed | CT: 9mm ossified; 30% canal residual |
Chronological Medical Record
Injury date: February 3, 2023 — Records sorted oldest to newest
Chronological Timeline
Imaging Reports
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FEB 03, 2023 — DAY OF INJURY
Emergency Department Visit
Methodist Medical Center · Dr. Sarah Kline, MD
Clinic
Methodist Medical Center
Attending
Dr. Sarah Kline, MD
Diagnosis
Acute lumbar strain; rule out disc injury
Mechanism
MVA — rear-end collision at ~35 mph
IV ketorolac 30mg; diazepam 5mg PO for muscle spasm
Lumbar X-ray ordered — no acute fracture identified
Discharged with naproxen 500mg BID, muscle relaxer, follow-up in 5 days
Visit Summary
Patient presented to ED following rear-end MVA reporting immediate onset severe low back pain radiating to left leg. Neurological exam showed intact sensation with mild left leg weakness. Discharged with pain management protocol and instruction to follow up with primary care or spine specialist.
FEB 14, 2023 — 11 DAYS POST-INJURY
MRI Lumbar Spine — Without Contrast
Advanced Imaging of Fort Worth · Dr. Kevin Marsh, MD (Radiologist)
Clinic
Advanced Imaging of Fort Worth
Ordering Physician
Dr. Sarah Kline, MD
Interpreting
Dr. Kevin Marsh, MD
Study Type
MRI Lumbar — T1/T2 sagittal, axial sequences
IMPRESSION — Scraped Word for Word
1. Posterior disc herniation at L4-L5 with associated annular fissure measuring approximately 8mm in AP dimension, contacting and mildly compressing the descending left L5 nerve root within the lateral recess.
2. Mild disc space narrowing at L4-L5 compatible with early degenerative disc disease, likely accentuated by acute traumatic injury.
3. Straightening of the normal lumbar lordosis, consistent with muscle guarding or spasm.
4. No fracture, subluxation, or acute osseous abnormality identified.
5. L5-S1: Mild diffuse disc bulge without significant nerve root impingement.
2. Mild disc space narrowing at L4-L5 compatible with early degenerative disc disease, likely accentuated by acute traumatic injury.
3. Straightening of the normal lumbar lordosis, consistent with muscle guarding or spasm.
4. No fracture, subluxation, or acute osseous abnormality identified.
5. L5-S1: Mild diffuse disc bulge without significant nerve root impingement.
Visit Summary
First post-injury MRI confirms L4-L5 posterior disc herniation with left L5 nerve root contact, consistent with patient's radicular symptoms. Radiologist notes loss of normal lumbar lordosis suggesting significant paraspinal muscle spasm. Findings support structural injury causally linked to the February 3rd MVA.
FEB 22, 2023 — 19 DAYS POST-INJURY
Orthopedic Spine Consultation
Texas Spine & Orthopedic · Dr. Ramon Castillo, MD
Clinic
Texas Spine & Orthopedic
Doctor
Dr. Ramon Castillo, MD
Diagnosis
L4–L5 Disc Herniation w/ Left L5 Radiculopathy
Pain Scale
7/10 at rest · 9/10 with activity
Physical therapy 3x/week × 8 weeks prescribed
Lumbar epidural steroid injection (LESI) recommended at L4-L5
Gabapentin 300mg TID initiated for neuropathic pain; continuation of naproxen
Visit Summary
Orthopedic consultation confirms MRI findings with positive straight-leg raise on left at 40°, decreased left ankle reflex, and dermatomal hypoesthesia at L5. Dr. Castillo establishes conservative management protocol with expectation to reassess for surgical candidacy at 3 months if no improvement.
MAR 01, 2023 — 26 DAYS POST-INJURY
Physical Therapy — Initial Evaluation
Peak Performance Physical Therapy · Sarah Nguyen, DPT
Clinic
Peak Performance Physical Therapy
Provider
Sarah Nguyen, DPT
Diagnosis
Lumbar radiculopathy; functional limitation
Functional Score
Oswestry Disability Index: 62% (Severe)
McKenzie extension protocol, lumbar traction, ultrasound therapy
TENS unit application for pain modulation; heat/ice protocol
Core stabilization exercises introduced at low intensity
Visit Summary
PT initial evaluation documents severe functional limitations including inability to sit greater than 20 minutes, inability to stand over 15 minutes, and profound antalgic gait favoring left leg. ODI score of 62% confirms severe disability baseline. Therapist notes significant pain-inhibited ROM throughout lumbar spine.
APR 18, 2023 — 74 DAYS POST-INJURY
Lumbar Epidural Steroid Injection + Fluoroscopic Guidance
Texas Spine & Orthopedic · Dr. Ramon Castillo, MD
Clinic
Texas Spine & Orthopedic
Doctor
Dr. Ramon Castillo, MD
Procedure
L4-L5 Transforaminal LESI — Left-sided
Medication
Dexamethasone 10mg + 0.25% bupivacaine
Procedure performed under fluoroscopic guidance, contrast confirmed epidural spread
Patient tolerated procedure well; 40% subjective pain relief immediate post-procedure
Follow-up in 6 weeks to assess benefit; series of up to 3 injections planned
Visit Summary
First lumbar epidural steroid injection delivered to the left L4-L5 foramen after conservative measures provided insufficient relief. Fluoroscopic confirmation of correct needle placement and contrast spread to the target nerve root. Patient reported 40% immediate relief, though noted this will require 72-hour assessment for full therapeutic response evaluation.
X-Ray
FEB 03, 2023
Lumbar Spine AP & Lateral
Methodist Medical Center · Dr. Priya Anand, MD
IMPRESSION
No acute fracture or subluxation identified. Disc space heights appear preserved at all lumbar levels. Mild right lumbar convexity scoliosis of uncertain chronicity. Vertebral body heights and alignment grossly unremarkable. No gross osseous lesion.
MRI
FEB 14, 2023
MRI Lumbar Spine Without Contrast
Advanced Imaging of Fort Worth · Dr. Kevin Marsh, MD
IMPRESSION
1. Posterior disc herniation at L4-L5 with annular fissure (~8mm AP), contacting descending left L5 nerve root.
2. Mild disc space narrowing at L4-L5; early DDD accentuated by acute trauma.
3. Straightening of lumbar lordosis — muscle guarding/spasm.
4. No fracture, subluxation, or acute osseous abnormality.
5. L5-S1: Mild diffuse bulge without significant nerve root impingement.
2. Mild disc space narrowing at L4-L5; early DDD accentuated by acute trauma.
3. Straightening of lumbar lordosis — muscle guarding/spasm.
4. No fracture, subluxation, or acute osseous abnormality.
5. L5-S1: Mild diffuse bulge without significant nerve root impingement.
MRI
AUG 09, 2023
MRI Lumbar Spine — Follow-Up
Advanced Imaging of Fort Worth · Dr. Kevin Marsh, MD
IMPRESSION
1. Persistent L4-L5 posterior disc herniation — no significant interval change in size (8mm AP). Left L5 nerve root contact unchanged.
2. Interval increase in disc desiccation at L4-L5 compared to February 2023 study, progressive degenerative changes.
3. New mild facet arthropathy at L4-L5 bilaterally.
4. Lumbar lordosis partially restored compared to prior study.
5. No new fracture, cord signal abnormality, or epidural collection.
2. Interval increase in disc desiccation at L4-L5 compared to February 2023 study, progressive degenerative changes.
3. New mild facet arthropathy at L4-L5 bilaterally.
4. Lumbar lordosis partially restored compared to prior study.
5. No new fracture, cord signal abnormality, or epidural collection.
CT
NOV 14, 2023
CT Lumbar Spine — Surgical Planning
Methodist Medical Center · Dr. James Wu, MD
IMPRESSION
1. Posterolateral disc herniation at L4-L5, left paracentral, with ossification of herniated nuclear material, measuring 9mm in greatest dimension.
2. Left lateral recess stenosis at L4-L5 with significant narrowing estimated at 30% residual canal diameter.
3. Moderate to severe facet arthropathy L4-L5 bilaterally with vacuum phenomenon.
4. Pedicle morphology and bone density suitable for instrumented fusion if operative intervention pursued.
5. No spondylolisthesis. Adjacent levels within normal limits.
2. Left lateral recess stenosis at L4-L5 with significant narrowing estimated at 30% residual canal diameter.
3. Moderate to severe facet arthropathy L4-L5 bilaterally with vacuum phenomenon.
4. Pedicle morphology and bone density suitable for instrumented fusion if operative intervention pursued.
5. No spondylolisthesis. Adjacent levels within normal limits.
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