41 years Female (DOB:1/4/1975)Reason: hx lumbar med L5-S1 1 month ago. c/o LBP, left leg pain, foot drop. Eval for epidural scar, abnormality or changes History: c/o LBP, left leg pain, foot drop.Referring Attending: EDWIN RAMOS Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact. No abnormal enhancing lesions are appreciated in the lumbar spine.At L5-S1 there is loss of disc space height, disc desiccation and a left lateral recess disc extrusion. The patient status post left hemilaminectomy at this level. Disc material extends into the left lateral recess and compresses the nerve roots at the left lateral recess. In addition there is some soft tissue thickening on top of the disc extrusion at the left lateral recess associated with some contrast enhancement. There is some associated contrast enhancement surrounding the disc extrusion. There is additional contrast enhancement at the left lateral recess. There is contrast enhancement along the left medial paraspinous tissues and the adjacent subcutaneous tissues at the surgical site which is likely postoperative in nature.At L4-5 there is no significant compromise to spinal canal or neural foramina.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
Since the prior exam patient has undergone left hemilaminectomy at L5-S1. There is some soft tissue thickening at the left lateral recess at L5-S1 which affects the nerve roots at the left lateral recess. This could represent postoperative change, disc material or inflammation due to infection. Additionally the left lateral recess disc extrusion has not changed substantially since prior exam.