Unspecified fall, initial encounter [W19.XXXA] / Muscle weakness (generalized) [M62.81], Reason for Study: ^Reason: 79F with multiple falls and RLE weakness, some incontinence too, h/o amyloidosis, ?spinal tumor, ?nerve impingement, For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is normal lumbar lordosis. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The signal of the visualized cord is normal. The conus medullaris terminates at the L1-2 level.There is no evidence of abnormal enhancement, cord compression or mass. Degenerative changes are specified by the intervertebral level as follows: T12-L1: Disc desiccation, no neuroforaminal narrowing or spinal stenosis. L1-L2: Disc desiccation, with mild bilateral ligamentum flavum thickening. No neuroforaminal narrowing or spinal stenosis. L2-L3: Disc desiccation, no neuroforaminal narrowing or spinal stenosis. L3-L4: Disc desiccation, diffuse bulging of disc with mild bilateral ligamentum flavum thickening result minimal spinal canal stenosis. No neuroforaminal narrowing or spinal stenosis. L4-L5: There is grade 1 anterolisthesis of L4 on L5. Associated with bilateral ligamentum flavum thickening, spinal canal at this level shows moderate to severe spinal stenosis. No neuroforaminal narrowing or spinal stenosis. L5-S1: Disc desiccation, diffuse bulging of disc with bilateral ligamentum flavum thickening indicates minimal spinal canal stenosis. No neuroforaminal narrowing or spinal stenosis.
1. Grade 1 anterolisthesis of L4 on L5 with moderate to severe spinal canal stenosis.2. Degenerative spondylosis of the lumbar spine including various degree of spinal stenosis as described above.3. No evidence of spinal cord compression.