HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman.  He is complaining chiefly of persistent lower back pain.  He states the pain is of a rather constant nature.  He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back.  He states he has difficulty with prolonged standing or sitting.  He can only stand for about 5-10 minutes, then he has to sit down.  He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain.  He has difficulty with bending and stooping maneuvers.  He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot.  He gets numbness along the lateral aspect of the foot itself.  He also describes chronic pain complaints with associated tension in the back of his neck.  He states the pain is of a constant nature in his neck.  He states he gets pain that radiates into the right shoulder girdle area and the right forearm.  He describes some numbness along the lateral aspect of the right forearm.  He states he has trouble trying to use his arm at or above shoulder height.  He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity.  He describes pain at the anterior aspect of his shoulder, in particular.  He denies any headache complaints.  He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person.  He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck.  He lost his footing and fell.  He reached out to grab the hand railing.  He fell backwards on his back and his right shoulder.  He had immediate onset of shoulder pain, neck pain, and low back pain.  He had pain into his right leg.  He initially came under the care of Dr. H, an occupational physician in Modesto.  Initially, he did not obtain any MRIs or x-rays.  He did undergo some physical therapy and received some medications.  Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful.  The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990.  He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat.  He continues with rather persistent pain in his right shoulder.  He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff.  The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories.  He felt that the patient might require a cortisone injection or possibly a surgical intervention.  The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck.  There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels.  The patient was also seen by Dr. P, a neurologist for a Neurology consult.  It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities.  The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994.  He returned back to regular duty.  Dr. N declared him permanent and stationary on 04/04/1995.  The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer.  At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician.  Dr. N took him off work again.  He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon.  He had a new MRI of his lumbar spine performed.  The MRI was performed on 05/20/1997.  It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis.  The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam.  Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation.  Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive.  The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left.  Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities.  The patient did see Dr. R for a neurosurgical consult.  Dr. R evaluated both his neck and lower back pain complaints on several occasions.  Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks.  The patient underwent these injections with Dr. K.  The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections.  It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine.  Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness.  The patient also was noted to have a C4-5 with rather severe degenerative disc disease.  He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6.  Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease.  He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1.  He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain.  He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms.  He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him.  He is currently taking no medications to manage his pain complaints.  He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury.  He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician.  The patient states he has not been back to work since.  He has since applied for social security disability and now is receiving social security disability benefits.  The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful.  Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,nan