Question: Lumbar Spine MRI results: lumbar spondylosis with moderate spinal stenosis at L-3-L-4 & severe spinal stenosis @ L4-L5. Cervical Spine MRI results: asymmetric narrowing of the \left neural foramina is identified at the C2-3, C3-C4 and mainly at C4-C5 level. Findings secondary to degenerative changes in the facet joints. Small soft tissue structure seen in the anterior cervical canal at C6-C7 level representing a bulging disc or small herniated disc. EMG/NCV results: showed electrophysiological evidene of mild bilateral median neuropathy at the wrist (carpal tunnel syndrome). There was also evidence of chronic left lumbar (L4) radiculopathy. There was no evidence of cervical radiculopathy or active denervation the needle EMG examination. In patients with small sensory polyneuropathy NCV is typically normal. Clinical correlation should be applied. The EMG/NCV test was done after the MRIs of the neck & lumbar. EMG/NCV does not support my symptoms. What are the MRIs these test indicating if they do not match the EMG/NCV? My symptoms: Symptoms reported to my primary care physician prior to MRI & EMG/NCV test: 1. Lower back pain (painful pressure on the lower back) (MRI results – provided) 2. Muscle spasms to upper back from back pain stiffness 3. Muscle cramps on lower legs and/or thighs (EMG/NCV test pending: 14 XXXXXXX 2013) 4. Trouble sleeping due to back pain & pain on toes 5. Hands and ankles swelling – with painful joints (+ CCP antibody test results provided)** 6. Aching back from sitting, driving & lifting 7. Performing simple task and normal work functions are difficult and sometime unbearable 8. Grocery shopping difficult – can add to cart but cannot bend to remove groceries from cart checkout – is painful 9. Can only walk short distance from car to store – before pain at hip socket & buttocks starts 10. ADL’s affected - can’t sweep, mop or dust – hired housekeeper 11. Prolonged sitting causes lower back & pain at the ball & socket joint on my hip 12. Shooting leg pain with painful, burning, pins pricking on toes 13. Numbness, muscular weakness, pins and needles & tingling on toes and finger tips 14. Painful to make a tight fist, unable to open cans, bottles or jars 15. Difficulty moving & controlling leg pain, pain starts as shooting leg pain 16. Simply bending forward can trigger severe back pain & muscle spasms’ 17. Sciatic back pain, acute & chronic back pain 18. Twitching right thumb, twitching right eye, 19. Sitting up from lying position in bed is painful – need to roll out of bed 20. Loss of urine post voiding – urine dribbles after tissue wipe 21. Post voiding – when going from sitting position to standing position - Need to immediately sit again to void – happens at least 1-2 times after voiding (reported at Pain Management Clinic) Referral for Evaluation & Treatment • Moderate Positive RA [CCP AB = 47 Units (40-59)], 2nd ESR 12 IU/ml (<14) 1st ESR 13 IU/ml) • Morning joint stiffness - lasts at 2-3 hours before joints feel loose – limited ROM w/shoulders • Painful joints on hands, fingers & ankles • Joint swelling, in the hands – ankles – joints are puffy & contributes to stiffness • Weakness –making a tight fist, holding objects ≥ 5 lbs; walking 20-30 min (triggers back/leg pain) • Redness and warmth - joints feel warm and look red on hands. • Exhausted – unable to sleep throughout the night • Chest pain – on & off • Heavy breathing – while walking – (noticed by others) • Eyes – are sometimes red &/or occasionally painful • Jaw pain – referral appointment for Endodontics (evaluation & treatment) last dose AB’s 2 wks ago Medications: • Flexeral (Cyclobenzapine) 10 mg - ½ to 1 tablet every 8 hours (24 mg q day) • Ibuprofen 800 mg - 1 tablet 3x/day PRN pain • Lidocaine Patch 5% q 12 hrs. (one on lower back & 1 on thoracic area) • Aleve 220 mg 2 tablets BID • Phentermine 37.5 mg QD • Amoxicillin 500 mg TID (last dose 03 XXXXXXX 2014) • Vitamin B12 (2000 mcg QD) As well as 1. Loss of urine post voiding – urine dribbles after tissue wipe 2. Post voiding – when going from sitting position to standing position - Need to immediately sit again to void – happens at least 1-2 times after voiding. Thanks, XXXX age correction 63 years

For chronic back pain & neck pain I am seeing Consultants in Pain Medicine who want to do injections to my back & neck. Pharmacological therapy includes: Tramadol & Hydrocodone PRN. I get dizzy spells from the medications & can't drive while on these meds. When I don't take the pain returns. The numbness, thingling and burning on my toes & fingertips continues. I have had various falls (2) within the past month and still find it difficult to sit/walk for prolonged periods of time (1-2 hrs). I have been taking 2500 mcg VB12 & Folic Acid too for the sensations in my fingers & toes (2 mos). I am an RN - when I take the pain meds, my concentration is slow & have difficulty reading to understand. Without pain meds - the pain gets worse to back & have difficulty walking due to sciatic pain. Knees also lock up - have bone spurs on both knees. What is the best test to confirm for this type of disability?

Since your last recommendation I went to my PCP and he gave me a RX for a 4 legged cane & bilateral splints for TCS. I have fallen 2x because my knee locks & my leg feels numb. I have another appt to see with the pain clinic to do steroid injections to see if that helps. I had mild back pain since 2006-2007 and the back pain has progressed. With my RA & back pain I am constantly working on one problem or another. B12 level was 334 pg/ml (normal range 200-1100) and my MD started me on B12 2500 mg QD but not D3. How much Vit D3 should I take?