MEDICAL LETTER

To whom it may concern,

My patient, Mrs. Vaasuhi, date of birth : 07th Feb. 1949, presented to our clinic office on
03th Nov. 2013, with severe lower back pain {when she was prolonged sitting), chronic
intermittent low back pain. Possible Lumbar disc lesion. Other health problem : diabetic.

Physical examination
1. Upper limb:
a) Motoric system: Bicep reflex (-/-)
b) Sensoric system: non abnormality detected

2. Lower limb:

a) Motoric system: No Patella reflex , No Achilles reflex

b) Sensoric system: she just feel dull on medial side

c) Vibration : right leg; digiti 1,2,4,5

Radiological Findings (MRI of the Lumbar spine on 29nd October, 2013)

Impression :

 Minimal Spondylolisthesis Grade I at L4-5,

 Lesion at rightaspect of L5 vertebral body, diameter appr. 1.7 cm, suspected
hemangioma.
 Mild spondylosis and degeneration of lumbar and facet joint arthrosis, particulary
lower lumbal.
 Bulging and right foraminal disc protrusion of L4-5 noted, accompanied with
narrowing of right neural foraminal and minimal at left neural foraminal, suspect
irritation of both exiting nerve (right > left)
 Bulging and right paracentral protrusion of L5-S1 disc noted, that mildly push right
traversing nerve and minimal narrowing of right neural foraminal, suspect mild
irritation of traversing nerve.
 Mild canal stenosis noted at L4-5 due to listhesi, bulging protrusion of dis,
hypertrophy of facet joint and flaval ligament
Working diagnosis

Minimal Spondylolisthesis Grade I (L4/5), possible/suspected hemangioma at L5, Disc

Protrusion ( L4/5, L5/S1), Canal stenosis at L4/5, C5/6, C6/7 disc lesion noted on MRI,
Idiopatic scoliosis

Recommended treatment :

1. Decompression therapy (DT) long term (6-12 month) for 2 times a week ideally.
2. Physiotherapi long term (6-12 month) for 2 times a week ideally.
3. Spesific SpineCor® Rehabilitation Exercise(SCRE) long term(6-12 month) for 2
times a week ideally.
4. SpineCor® bracing
5. Chiropractic is not recommended for early stages.

FollowUp

We follow up the patient based on her condition. The aim of therapies are to reduced the sym
ptoms (frequency and intesity of the pain), improve the quality of life, and to restore the body
function (motoric and sensoric system).

Treatment that has been done in our clinic :

1. Decompression therapy (DT) : lumbar therapy 32 times and cervical therapy 23 times
2. Physiotherapi : 33 times
3. Chiropractic : 19 times
4. Spesific SpineCor® Rehabilitation Exercise(SCRE) : 5 times

Your sincerely,

Dr Irma Yunita
Physical examination

1. Upper limb:

a) Motoric system: Bicep reflex (-/-)

b) Sensoric system: non abnormality detected

2. Lower limb:

a) Motoric system: No Patella reflex , Achilles reflex (???)

b) Sensoric system: she just feel dull on medial side

c) Vibration : ??

Radiological Findings (MRI lumbal and whole spine on 22nd August, 2015)

1. From sagital view is seen protrusion of L4-5 disc caused moderate canal stenosis

From axial view is seen protrusion of L4-5 disc caused narrowing of neural foramens and
nerve irritation at
both sides.

2. Disk degenerative disease at L5-S1

3. No abnormality detected at cervical’s disc

Working diagnosis:

HNP at L4-L5 disc with moderate canal stenosis.