76 years Male (DOB:8/12/1939)Reason: hx L3-4 bilateral Lami s/p 1 month. eval for stenosis above/below. History: c/o LBP, pain down legs when standingPROVIDER/ATTENDING NAME: EDWIN RAMOS 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.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is some disc desiccation present at this level. There is some mild ligamentum flavum hypertrophy present at this level.At L4-5 there is loss of disc space height, diffuse disc bulge and endplate reactive changes with a Schmorl's node. The endplate reactive changes are mildly elevated in signal on T2 and predominantly high signal on T1. There is some ligamentum flavum hypertrophy present at this level. There is partial effacement of the fat at the right lateral recess at this level. There is some partial effacement of the fat surrounding the right-sided exiting nerve roots at this level.At L3-4 there is loss of disc space height and disc desiccation associated with a large right lateral recess disc extrusion. Disc material extends into the right neural foramen and also effaces the fat at the right lateral recess at this level. There is a superimposed disc bulge at this level. There are endplate reactive changes present at this level which are high signal on T1 and T2 associated with small Schmorl's nodes atThere is a 17 x 14 mm axial dimension T2 hyperintense focus present along the right L3 lamina which represents a laminotomy defect.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.
1.There is a large right lateral recess disc extrusion present at L3-4 which encroaches on the nerve roots at the right lateral recess and in the right neural foramen at this level. It also creates mild degree of spinal stenosis.2.Status post right laminotomy at L3-4.3.There is mild encroachment of the right-sided exiting nerve roots at L4-5 due to a disc disease.