Clinical Intake — Spondylosis without myelopathy or radiculopathy

Mr. Patterson is a 57-year-old male with an eight-month history of chronic low back pain and intermittent left lower extremity discomfort attributed to spondylotic changes at the L4-L5 level with associated facet arthropathy on recent spinal imaging. He has completed a full course of structured physical therapy with minimal improvement, trialed anti-inflammatory and muscle relaxant therapy with only partial relief, and underwent a transforaminal epidural steroid injection that provided only transient benefit lasting approximately two weeks. Neurological examination is currently non-focal, though he reports pain with spinal extension and continued functional limitation with activities of daily living. Given the failure of conservative measures, Dr. Patterson recommends further evaluation to guide management.