CLINICAL RECORDS
1. 1976- Aug 1979, Toxic Chemical Exposure to nuclear missile fuels Aerozine 50-50, N-Nitrosodimethylamine (NDMA), Inhibited Red Fuming Nitric Acid, HYDROGEN CYANIDE, and TCE, many other chemicals, list available.
2. 1979, May 7 first muscle spasms during USAF military active duty. S=> upper left eyelid twitching for 3 days long with (NECK + LEFT shoulder muscles spasms also occasionally) soreness since last night, Redness x T-T1 days. Vision good. Not a glass wearer. No dysplasia. O=> neg exam. A=> L eyelid spasms, DX: ? Etiology P=> K+, CA + levels. Advise that anxiety, lack of rest, stimulants, etc can cause these type of problems. Oliver R Seaman MD. DMAFB HOSPITAL.
3. 1980, Dec 27, I was treated at the Tucson, AZ VA Medical Center for sudden onset of pain of the neck with radiation down left arm. I received injections to the left Scapula. DX: Peripheral neuritis… is the inflammation of nerves. It is also known as peripheral neuropathy. 5cc Marcaine + 4 mg Dexameth, injected with good results.
4. 1981, Feb 9th at VA Complaint of constant pain. Apparent relief obtained by supraclavicular block. Feel pt’s symptoms are neurologic.
5. 1984, Nov 10, Hospitalization, Tucson Medical Center, due to left shoulder/neck muscle pain spasms neck and back. Lumbar puncture: High Level of protein (137) found in spinal fluid. Neuro consult. Dr. Smith and Dr. Rotkis involved.
6. 1986 approximately, Left shoulder blade spasms off and on 2yrs, injected 0.5 HDTBA and 0.5 Marcaine Dr. Rotkis, Tucson
7. 1986 approximately Follow-up Myalgias Dr. Rotkis
8. 1987, July 31, Muscle spasms in left shoulder up into neck DX: Musculoskeletal (MSK) pain, left shoulder with radiculopathy. (Positive Adson’s test. Thoracic outlet syndrome?) Dr. Garfield.
9. 1989, Dec 7, Numbness in left leg after jogging with Muscle knot in Left upper back. DX: None Very unusual. Dr. Rotkis. F/u with Dr. Garfield.
10. 1990 December 20, Dr.Sluss, Neurologist, Green Bay WI. Letter to Dr. McKenzie, Ortho Green Bay WI. Bilateral hand tingling, legs weak and Posterior neck pain. Described by me as same as hospitalization in Tucson noted. DX: possible cervical spine disease, herniated disc. T4 slightly tender. Negative MRI results. Hyperactive left knee jerk.
11. 1992, April 1, D.O. Owens. Acute pain in left intrascapular region. Chronic problem. Posterior cervical tenderness on the left side C4. Trapezius-tenderness on the left side. Trigger point injection in the levator scapulae. Brief course of Neuroprobe.
12. 2002, April 16, Metatarsalgia Dr. Brusky, Dr. Komp.
13. 2002, Sept 30, lower back discomfort. Dr. Brusky. DX: Back pain. P: Treatment for musculoskeletal back pain.
14. 2003, Nov 21, Dr. Ahlskog Neurologist Mayo Clinic Neurology. “There is some single explanation for all these, but I do not know what it is.” The peripheral nervous system must be likely involved. DX: Subacute development of multiple symptoms including numbness and pain in the distal feet, thoracic outlet symptoms, diarrhea, impaired urinary emptying, and impaired ejaculate.
15. 2003: Mayo urinary workup. Urinary dysfunction - CNS possible. Bladder (starting , nocturnal, dribbling, bowel (diarrhea issues) neurogenic bladder possible. Urinary scopes in 2003 and 2008. Nothing found that explains problem.
16. 2003, Jan 29, Joint, muscle pains, Dr. Brusky, Dx: Myalgia, Arthralgia (joint and muscle pain)
17. 2008 11 14th , VA Dr Budzak. Fell to floor with back pain this morning. THE START OF MAJOR LOW LUMBAR BACK PAIN
18. 2008, 11-14. VA Dr. Budzak , trigger points massaged and pain went into both legs.possibility of acute sxs or anterolisthesis. Back flare ups interferes with walking. Weakness in legs fell to floor.
19. 2008, 11-24 VA PT for lower back pain. Teaching neutral spine position and transverse position. Gentle core strengthing. If prone on elbows aggravates his back. Change to knee to chest stretch and straight lying minicrunches. Transverse abdominus stabilization and making skinny exercise. 6 viists over two months.
20. 2008, 12-03, MRI at N.E.W. Axial loaded NO KNEE BOLSTER USED MRI. L5-S1 annular tear.
21. 2008, 12-03 Dr. Budzak says annular tear noted on MRI does not account for high pain. Feels pt has myofacial pain.
22. 2008, 12-09, Dr. Ozwald spine Prevea disagrees with Dr. Budzak, mechanical low back pain with L5 –S1annular tear. Left L5 transforminal injection recommended.
23. 2008, 12-18, Dr. Koch, Left L4/L5 injection Not L5-S1 by torn disc but by the bulge.
24. 2008, 12-22, Bone scan Prevea. Scattered degenerative changes. Nothing to account for pain level.
25. 2008, 12-23, Dr Ozwald follow-up. Symptoms are improved also groin pain lessened.
26. 2009, 04-06, Dr. Otts Aurora, review MRI. No disc degeneration, Minimal spondylosis and degenerative changes. L5 –S1annular tear. See Dr. Araujo for pain management and IDET. See chiropractor. If no improvement consider disc replacement or fusion at L5-S1 after a Lumbar discography.
27. 2010 DX: Atypical Meniere’s or vestibular migraine. (Dr. Pyle UW Health Professor ENT)Tinnitus
28. 2011, 01-12 LOW Back nerve PAIN Key Largo, FL VA. RX:Diazepam.
29. 2012: Aug 22. DX: Right arm cubital tunnel syndrome with prominent ulnar neuritis at the elbow, with EMG findings of mild ulnar neuropathy. Chronic neck pain; r/o right cervical radiculapathy. Limited left shoulder range of motion, chronic. Dr. Koch Prevea spine clinic.
30. 2012: War Related Illness and Injury Study Center “WRIISC”. Located at the VA, New Jersey. DX: fibromyalgia, memory and executive functioning disorder, Sensory polyneuropathy, and depression.
31. 2012, 01-13. Dr Taub at VA Miami. Pain worse with extension maybe related to a lumbar facet syndrome. Order MRI
32. 2012, 08-05 epidural injection Dr. Koch prevea. Depomedrol. L5/S1.
33. 2012, Aug 13 EMG Dr Koch Mild right arm latency Ulnar/medial nerve.
34. 2012 Sept 06: Static Positioning Tests at UW Health, Madison. Weak right beating nystagmus was recorded in the supine, head left and caloric test positions with vision denied. Up-beating nystagmus was recorded in the supine, head left and caloric test positions with vision denied. Bithermal tests not done due to right ear perforation.
35. 2012 Nov 1: Ulnar nerve transposition surgery right arm, Dr. Cullen. No help with nerve pain symptoms DX: Small fiber
36. 2013: Prevea Neurology, Dr. Battacharyya. Numbness and tingling hands and feet (DX peripheral neuropathy). Right arm - Ulnar nerve transposition no help.
37. 2013, 10-29 Accupuncture. Dr. Guo
38. 2014, 01-09 Dr. Koch Prevea. Epidural injection L4/L5 Depo-Medrol.
39. 2015, 02-02 Dr. Steed, Key Largo, Hospital ER visit feels like pinched nerve back.
40. 2015, 04-04, Dr. Koch Prevea. Epidural injection L4/L5 Depo-Medrol.
41. 2015 08-20, Dr. Koch Prevea. Epidural injection L4/L5 Depo-Medrol.
42. 2015, 09-16. Dr Koch says no more epidurals. Multifactorial back pain, myoflacial pain and lumbar facet arthritis. Small tear non-significant in his opinion. He believes it is fibromyalgia amplifying the pain. LYRICA prescribed. Filled by VA but discontinued due to stomach pain etc.
43. 2015, 10-01 Met with Dr Bhattacharyya, After PT of the neck right arm ulnar nerve burning symptoms could it be from C7. Could do an epidural to C-7 to see if that helps. It may help pinpoint another issue? Also suggested for memory to see Dr. Smet for another evaluation. Could do another MRI but the one already shows a bulge at C-7.
44. 2015 Nov 04. Dr Koch follow-up PT. Nothing further to do with back. More Lyrica suggested.
45. 2015 Nov 19, Dr. Koch L4-L5 facet steriod injection boths sides. Numbing meds seem to help within first hour. 5 days later no help yet. He re-studied the MRI and says arthritis is moderate in those facets. Willing to try.
46. 2015 Dec, 2. follow-up after injections to L4-L5 facet. In my opinion it was unsucessful in helping. Pain 6/10 and 10/10 acute. Lumbar like pinching nerve pain has increased to point of needing crutches to walk. Dr. Koch is now going to try injecting L5-S1 the torn disc.
47. 2015 12 03. Epidural injection at L5-S1 the torn disc. Dr. Koch.
48. 2017: Nystagmus: Three visits with UW Health in Madison, WI, video taping of eye movement with special video goggles. Nystagmus was mostly down beating and upbeating with Dix-Hallpike in neutral and straight head hanging DX: Sometimes. Mostly down beating lying on back and head lowered and upbeating when raised to the sitting position chin tucked to chest. Maneuvers for BPPV “crystals in anterior canal not successful. Location of supposed crystals in the most unlikely location the anterior canal. Anterior canal BPPV is very rare because the anterior canal is the highest part of the ear. AC BPPV is probably rare because debris would naturally tend to fall out of the posterior half of the anterior canal, and getting debris into the anterior canal would not be easy.https://www.dizziness-and-balance.com/disorders/bppv/acbppv/anteriorbppv.htm. I have Vertigo/nausea that is heat related, watching moving objects in stream, flickering lights, along with positional triggers.
49. 2017 Nov 17. Lower back pain worse. Appt with Dennis King DC, CCSP, FACO, ART at Howard Chiropractic. Heat and stretch Itital consut I had to pay out of pocket. Suggested humid heat and use my tens unit for 20 min four times a day.
50. 2017 Nov 19. Followup with Dennis King DC, CCSP, FACO, ART at Howard Chiropractic.
51. 2018 Jan 24. Lower right back muscle spasm. Dr. King adjustment to SI joint and upper spine. No help on upper spine pain. Laser on lower back. Feels L4-5 are involved in numbness pain in right leg.
52. 2018 01 26. Met with Dr. Koch Spine Clinic Prevea. He had no record of him signing letter for the VA RX: Lyrica. My notes show he gave me the prescription and wrote a note to VA to fill. After examination Dr. Koch said “you probably have a subset of fibromyalgia”. I said “I have had fibromyalgia diagnosis for years”. He must have not read the previous diagnosis in the Prevea system. RX Lumbar spine MRI. I question why not the SI Joints as that is where he has been injecting me for the last 3 years. He made the SI joint diagnosis after injecting me in L4-5 left side for years prior with no benefit. Back lower and Leg pains continue. Heat on lower back seems to help. IB taken. He apologized for the error.
53. 2018 01 24. Lower back muscle spasm that immobilized me. Severe pain and muscle knot left lower back. Called Dr. King for he got me in to see him. Manipulated my SI joints and cold laser treated my muscle knot. I took Diazepam three times ½ pill each time and it seemed to help. Also used my back support during the night to prevent pinching nerves accidentally. Heat to lower back all evening and next morning. Pain ears yet bilateral. Pain both legs and more numbness in right leg. Dr. King thinks L4-5 involved also.
54. 2018 01 09. Dr. Metz Orthopedics. He says something is not right medically. We will meet after EMG next week and discuss hand deformity causes. EMG of arms is inconclusive. Dr. Metz checks left Ulnar nerve and I jump when he slightly touches it. Dr. Metz (Prevea Orthopedic surgeon) concludes the EMG is not catching my issue thisa time.
55. 2018 02 01. MRI SI joints. Nothing found.
56. 2018 08 15. MRI thoracic spine ordered by Dr. Koch. I begged for a MRI of my T spine. Pain in the T spine. Radiologist Dr Kolanko, Green Bay Radiology, missed the scalpel sign of the arachnoid web. This was not found until 2021 12 11 at Oro Valley Hospital ER when I had a competent radiologist read my T spine MRI
57. 2019 01 21. Dr Kaufmann at Bellin Neuro. Gave him list of history on neuro issues. He ordered a MRI of the head to look again at deep white matter spots. Mind made up his mind that it is vestibular migraine. Only about 20 minutes spent.
58. 2019 07 18 Dr. Ots your clinic notes on 07-18-2019 say my Thoracic spine MRI was reviewed for abnormalities which may explain my mid to low back pain and your review says “unremarkable of the 2018 09 14 T spine” (attached and you have the full MRI on file which you can review). My question is: How was this T-spine T5-6 Arachnoid web missed by you? I think I am due an explanation.
59. 2019 07 23 Dr Ots follow-up. Going over the CT ordered. Abdomen CT showed mild sclerosis in the SI joints, He offered to pin the SI joint and fuse it.
With due respect,
Your notes clearly state that I had mid back pain along with low back pain since 2003. Why would I have asked for you to look at my Thoracic spine MRI if I only had complaints of low back pain?
My thoracic MRI clearly shows that the spinal cord is compressed at T5. Why would you not tell me about that other than you missed it or are not familiar with arachnoid webs on the MRI and I have a history of mid back pain?
Attached is the spinal cord compression axial view. No different then when you looked at my MRI in 2019. I think there is a lesson here. A radiologist at Aurora should have looked at the thoracic MRI if you can not see there was an issue with a history of complaints for mid back pain.
60. 2019 08 20 L4-5 back issue prevea urgent care. Gave me oxy for pain. That night my lower back totally went out I called Isa at Aurora.
61. 2019 08 21 MRI of Lumbar spine. L4-L5 Mild facet Arthropathy
62. 2019 08 22. Dr Dervish gave me an injection into L4-5. It helped greatly. Dr. Metz gave me injection into right elbow. Great help with pain.
63. 2019 08 21 MRI of Lumbar spine. L4-L5 Mild facet Arthropathy.
64. 2019 09 11. consult with Dr. Dervish Pain management at Aurora. Gave me two epidural injections in the last three weeks. SI and L4-5. Also gave me a Ketoralac ? mg NSAID shot in muscle IM.
65. 2019 09 23. L4-L5 injection by Dr. Dervish
66. 2020 01 09. Vertigo continues even sitting and tilting head back on couch. Took dramine to help nausea and dizzy spell. Walking is hare, used wheelchair to get around house. Getting in bed had terrible dizziness lying down on my back. Was able to lie on my side. During the night was able to roll on my back. Left message for Dr. Pyle. Nurse said she sent it onto him. No email from him! Sent another message that I took the dramine to him. Dr. Pyle gave me lorazapam for dizziness and Ondansetron for nausea.
67. 2020 06 11. Four Seizures type incidents while waking up in the morning. Only about 2 seconds each. Continued until 2021 June.
68. 2020 06 16. Neuro exam for what seems to be Seizures. Daytime monitor test 2 hours. No home monitor done.
69. 2020 07 24 Seen by Magan S. Upped my metroproral rx by 25 mg day. Cardio offered genetic testing for the antibodies. Seizures continue in the morning but are only about 3 seconds long.
70. 2020 08 31 Mayo trip for neuro. Dr. Chang not a very good listener although her Fellow gave her the info so it may not be her fault? Made comment about BPPV being the issue but was clearly told that BPPV had been ruled out. Neuro gave me Rizatriptan Benzoate 10mg for headaches that started already. Also gave me Prochlorper 10 mg 9 /day if needed for nausea.
71. 2020 09 10. Left back lower muscle spasm pain. Pain in both biceps muscles
72. 2021 11 29 Extreme pain in lower back. ER at St. Mary’s Hospital. MRI LUMBAR done yet again. Radiologist says minor L4-L5 PROTRUSION does not explain this extreme pain. Wheel chair bound for three days
73. 2021 12 11 Worst ever pain in back that I can’t even walk. Oro Valley, AZ ER. MRI total spine done with contrast. Arachnoid web in spinal column fluid (Very rare only 1-3% of spinal cysts is webs). Only 60 reported cases in medial literature as of 2021. Compressing T spinal cord. In wheel chair for 2 weeks. Worst ever pain. Headache behind right eye.
74. 2021 12 17 ER Tucson Medical Center. TMC does a CT mylogram with contrast in the spinal cannel. Does not show anything more than the MRI (waste of time). Pain continues, Dr Schmitz says go to ER to see Dr. Rivero neurosurgeon. He wants to operate and remove the whole arachnoid web from T3-T8. Huge operation as laminectomey from T3-T8.
75. 2021 12 17-30 multiple other neurology second opinions. Remove the web.
76. 2022 02 11 Dr. Ali A. Baaj removes arachnoid web in spine T4-T5. He claims success.
77. 2022 09 13. Attack of the low back for first time since operation by Baaj. 7 months after surgery. ER visit MRI of Thoracic spine shows that the growth is back same image as before showing Scalpel sign. Baaj says it probably never decompressed as it has been there for years.
78. 2023 01 03 appt with Baaj. Arachnoid web has no change in three months. Will not do any more surgery. Showed him lump in back and asked for an ultrasound on the phone. Denied. He has agreed to write a request to an imaging department to give me a FIESTA-C MRI if I find someone to do it! He is unwilling to expend any effort to find someone himself! He has never ordered one himself for any spine operation!
79. 2023 01 06. Low back attack stepping up ladder-symptoms the same as always. Finally after being told my low back lump is not a muscle knot by PT. I had an ultrasound at Oro Valley, Az Hospital. Indeed it is a hypo mass with no blood flow. Advised to get MRI.
80. 2023 03 05. Another attack where I can not walk.
81. 2023 03 06. Dr. Dumont and resident want to propose installing a shunt into the web to draining the CSF fluid.