Fit for Surgery Referral

Dear Dr. Sarah Jenkins Thank you for seeing the patient below. Re: Mrs. Eleanor Vance File: EV2024-007 I am writing to refer my patient, Mrs. Eleanor Vance, for an assessment to determine if they would be fit for the following surgery: Lumbar Microdiscectomy at L4-L5 level. Mrs. Eleanor Vance is known with Chronic lower back pain (M54.5), Lumbar disc protrusion (M51.26), and Hypertension (I10) and is currently using Amlodipine 5mg daily, Gabapentin 300mg three times daily. Surgical History: Appendectomy, 1998, Dr. Robert Sterling, St. Jude's Hospital Cholecystectomy, 2010, Dr. Helen O'Connor, Royal General Hospital Allergies: Penicillin (T36.0X5A) - rash, anaphylaxis Codeine - nausea, vomiting Social History: Non-smoker (Z87.891) Alcohol History: Occasional social drinker, 1-2 units per week. The patient presented with the following complaint: Mrs. Vance is a 58-year-old female presenting with a 6-month history of progressively worsening lower back pain radiating down her left leg to the foot. The pain is described as sharp and shooting, exacerbated by prolonged sitting and standing, and partially relieved by lying down. She reports associated numbness and tingling in the left great toe. Neurological examination reveals reduced sensation in the L5 dermatome on the left, with mild weakness in left ankle dorsiflexion (4/5). Straight leg raise test is positive at 45 degrees on the left. MRI spine shows a significant disc protrusion at L4-L5 on the left, compressing the L5 nerve root (M51.26). I am planning the following surgery: Left L4-L5 Lumbar Microdiscectomy on 1 November 2024 Your expertise would be greatly appreciated in assisting with an evaluation and assessment to determine if Mrs. Eleanor Vance would be fit for the planned surgical intervention. Thank you for your assistance and attention to this matter. Yours sincerely, Dr. Jonathan Clarke Neurosurgeon