Neurosurgery Patient Consultation Letter

Neurosurgeon Date: 01/11/2024 Mr. John Smith DOB: 15/03/1960 Hospital Number: HOS1234567 14 Elm Street Springfield ST1 2AB Dear Mr. Smith, Diagnoses: 1. Lumbar Spinal Stenosis, L4-L5 2. Degenerative Disc Disease, L4-L5 3. Sciatica, left leg Management Plan: 1. MRI Lumbar Spine with contrast 2. Physiotherapy referral for core strengthening and pain management techniques 3. Prescribed Gabapentin 300mg three times daily 4. Follow-up appointment in 6 weeks to review MRI results and treatment response History: It was a pleasure to see you on 01/11/2024 to review your health concerns. You are 64 years old and I appreciate the time you took to share details about your health and personal life. I have summarised our discussion below. You explained that your chief complaint is persistent lower back pain radiating down your left leg, which has been worsening over the past six months. You described the pain as a dull ache in your lower back with sharp, shooting pains extending into your left buttock and posterior thigh, occasionally reaching your calf. You find that the pain is aggravated by prolonged standing and walking, with relief obtained by sitting or lying down. You have tried over-the-counter paracetamol and ibuprofen, which provide minimal temporary relief. Your current medications include daily Aspirin 75mg for cardiovascular prophylaxis and Ramipril 5mg for hypertension. You report numbness and tingling in your left foot, particularly after walking for more than 10 minutes. You deny any bladder or bowel dysfunction, saddle anaesthesia, or significant recent weight loss. Your past medical history is significant for hypertension managed with medication, well-controlled Type 2 Diabetes Mellitus, and a remote history of a left ankle fracture 20 years ago. You have no known drug allergies. You are a retired civil engineer and live in a two-bedroom bungalow with your wife. You are generally active but your pain has significantly impacted your ability to garden and take long walks, which you previously enjoyed. You occasionally consume alcohol but deny smoking or recreational drug use. On examination, your gait was antalgic, favouring your left leg. There was reduced lumbar lordosis and mild tenderness on palpation of the L4-L5 intervertebral space. Straight leg raise test was positive at 45 degrees on the left, eliciting left leg pain. Motor strength was 5/5 in all muscle groups in both lower extremities. Sensory examination revealed diminished sensation to light touch in the L5 dermatome on the left. Deep tendon reflexes were 2+ bilaterally at the patella and Achilles. We discussed that your symptoms are highly suggestive of lumbar spinal stenosis with associated radiculopathy. We reviewed the conservative management options, including medication and physiotherapy, and the potential need for surgical intervention if conservative measures prove ineffective. We also discussed the risks and benefits of further investigations, specifically an MRI scan, which will provide detailed imaging of your spinal canal and nerve roots. You were advised to monitor for any worsening of motor weakness, new onset bladder or bowel incontinence, or increasing numbness, and to seek urgent medical attention if these red flag signs develop. Yours sincerely, Dr. Thomas Kelly MBBS, FRCS (Neuro) Consultant Neurosurgeon Enquiry: t.kelly@neurosurgerypractice.com Weblink: www.thomasnellyneurosurgery.co.uk cc: GP Dr. Eleanor Vance, The Family Practice, 12 High Street, Springfield, ST1 2BC