Summary for a second opinion
Illustrative example- Question for this visit
- Is fusion surgery the right next step, or are there other options to consider first?
- History in brief
- R. M., 58. Lower back pain with pain down the left leg since 2023. MRI in June 2023 showed a disc herniation at L4-L5. Twelve sessions of physical therapy in 2024. Epidural steroid injection in January 2026, with relief for about six weeks. A surgical consult on March 12, 2026 recommended spinal fusion.
- Medications
- Gabapentin 300 mg, three times a day. Naproxen 500 mg, as needed.
- Records gathered
- Riverside OrthopedicsLakeview ImagingNorthgate Physical TherapyDr. Patel, primary care
- May be missing
- The flexion and extension X-ray report mentioned in the March consult note.
- Questions to bring
- What on my imaging points toward fusion rather than another approach?
- What would you expect if I waited another six months?
- How long would recovery keep me away from work?
Prepared from the records in this file. Twice explains and organizes; the opinion comes from your doctors.