Pain Clinic Note

Date of clinic: 01/11/2024 Patient Particulars: Sarah Jenkins (15/03/1978) NHS No. 123 456 7890 Hospital No. SJ7890 Address: 123 Pine Street, Anytown, AB1 2CD Insurer: Bupa Letter to Dr. Emily White Copy to Dr. Mark Davies (GP), Ms. Susan Green (Physiotherapist) Dear Dr. White, I reviewed Sarah in my clinic today for a follow-up consultation. Review: Ms. Jenkins, a 46-year-old female, presented today for a follow-up regarding her chronic lower back pain. She was initially referred by her GP, Dr. Mark Davies, due to persistent neuropathic pain following a disc herniation at L4/L5 two years prior. She reports a slight improvement in pain intensity since her last visit six weeks ago, from an average of 7/10 to 6/10 on the Visual Analogue Scale. She has been diligent with her prescribed Gabapentin 300mg three times daily and has also engaged in regular physiotherapy. However, she expresses continued frustration with the impact of the pain on her daily activities, particularly her ability to sit for extended periods and perform household chores. She is keen to explore further intervention options to improve her quality of life. Discussions revolved around the long-term management of chronic neuropathic pain, including potential interventional procedures and psychological support. Examination: On examination, Ms. Jenkins appeared comfortable at rest. Vital signs were stable. Lumbar spine palpation revealed mild tenderness over the L4/L5 intervertebral space. Range of motion was limited in flexion and extension due to reported pain, with lateral flexion preserved. Neurological examination showed intact sensation to light touch and pinprick in both lower extremities. Motor strength was 5/5 in all major muscle groups. Straight leg raise test was negative bilaterally to 70 degrees. Deep tendon reflexes (patellar and Achilles) were 2+ and symmetrical. Summary: - Patient is a 46-year-old female presenting with chronic neuropathic lower back pain following an L4/L5 disc herniation. - Examination revealed mild tenderness at L4/L5 and limited lumbar range of motion due to pain. - Clinical impression is persistent neuropathic pain secondary to post-laminectomy syndrome. - Currently on Gabapentin 300mg TDS with reported mild improvement; no significant medication-related issues. - History of L4/L5 microdiscectomy two years prior. - Previous MRI showed post-operative changes with no significant re-herniation. The patient's presentation is consistent with ongoing neuropathic pain despite conservative management and previous surgical intervention. Her current symptoms significantly impact her daily functioning and quality of life. Diagnosis: 1. Chronic neuropathic lower back pain (Post-laminectomy syndrome L4/L5) Management Plan: 1. Continue Gabapentin 300mg TDS; review effectiveness and tolerability at next appointment. 2. Refer for a psychological pain management programme to address coping strategies and pain self-efficacy. 3. Discuss potential for a trial of lumbar epidural steroid injection with the patient at the next clinic visit. 4. Continue with regular physiotherapy, focusing on core strengthening and ergonomic advice. 5. Schedule a follow-up appointment in 8-10 weeks to assess progress and discuss interventional options further. Many thanks Yours sincerely Dr. Alex Carter, FRCA FFPMRCA Consultant in Pain Management Tasks: For Admin Team: - Book follow-up appointment for Ms. Jenkins in 8-10 weeks. - Send referral to the Psychology Pain Management team. - Distribute clinic letter to Dr. Emily White, Dr. Mark Davies, and Ms. Susan Green. For Self: - Review literature on interventional treatments for post-laminectomy syndrome prior to next consultation. - Prepare patient information leaflet on lumbar epidural steroid injections.