October 15, 2012 - City of Laredo

07/15/2011- Lt. Ramon had an MRI of the Lumbar Spine W/O contrast which showed minimal central disc
protrusion at L4-L5 with desiccation of the disc, without spinal stenosis or nerve root abnormality.
07/19/2011- Lt. Ramon was seen by Dr. A. Garza-Vale, he reviewed the MRI and found that the employee
had degenerative changes in the L4-L5 disc, an annular tear that was more left-sided consistent with left leg
pain, and some subligamentous protrusion of the disc. No compression of the nerve was seen, but this may
be due to the employee being in a lying position. Dr. A. Garza-Vale stated treatment options at this time
maybe surgery if approved or continue with conservative treatment.
08/15/2011 - Lt. Ramon was seen by Dr. F.J. Gutierrez continued with low back pain and remained off
work until next follow-up on 91201201 1 pending further evaluation.
08/26/201 1- Lt. Ramon had another diagnostic test of the Lumbar AP/Lateral/Flexion/Extension (Lumbar
Spine, Four views with weight bearing) which showed mild segment instability L4-L5 level.
09/16/2011-Lt. Ramon was seen at Institute for Mind & Body Wellness by Jose Gonzalez, MA,
LCDC,LPC,QMHP, for Presurgical Mental Health Consultation and is cleared for surgery.
09/20/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez and continued with low back pain and remained off
work until next follow-up on 1011 31201 1 pending further evaluation.
10/13/2011- Lt. Ramon was seen by Dr. F.J. Gutierrez and continueed with low back pain and remains off
work until next follow-up on 1 1/22/20 1 1 pending further evaluation.
10/26/2011- Lt. Ramon undergoes surgery, bilateral hemilaminectomy and foraminectomy at L4-L5 with
discectomy and Amphelos devices placement (Spinal Fusion). Dr. A. Garza-Vale was the surgeon
performing the operation.
11/14/2011- Lt. Ramon had diagnostic exam of Lumbar Spine-2 views-APILateral showing the employee
underwent interval surgery with laminectomy at L4-L5. A disc implant has been placed and appears in
appropriate position in L4-L5 disc space, and remaining lumbar spine is stable and unremarkable.
11/14/2011- Lt. Ramon was seen by Dr. A. Garza-Vale for follow-up after surgery, where he reviews the
diagnostic exam (x-ray), and stated that surgery was a success. The employee continues with foot drop, but
it has improved significantly; it may take a few months to fully recover though. Lt. Ramon is to start on an
at home walking program and stair climbing to regain function. A follow-up is scheduled in six weeks to
possible progress him to physical therapy or return to work.
11/22/2011 - Lt. Ramon is seen by Dr. F.J. Gutierrez continues with Low Back Pain and remains off work
until next follow-up on 12/20/2011 pending further evaluation.
Currently, Lt. Jaime Ramon is undergoing a home walking program and stair climbing to regain more
function. Although the employee continues with a slight foot drop, it is considerably better post-operative
and should not impede his healing. In accordance with ODG staff recommends 120-140 days which is
believed to be enough time for the employee to heal and complete rehabilitation.