right leg pain, postoperative status of L5S1. For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is evidence of right L5 laminectomy.Anterior epidural fat appears to be obliterated with soft tissue signal intensity which may indicate postoperative changes (granulation tissue), however, there is no evidence of adjacent nerve root compression.There is normal lumbar lordosis. The spine alignment is anatomic. 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 epidural space, thecal sac, and spinal cord are preserved with no evidence of spinal canal/neural foraminal narrowing. The conus medullaris terminates at the L1-L2 level.Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: no neuroforaminal narrowing or spinal stenosis. L4-L5: Diffuse bulging of disc which abuts thecal sac, otherwise unremarkable. L5-S1: Evidence of right L5 laminectomy with soft tissue signals within the anterior epidural fat which may represent postoperative changes such as granulation tissues. No evidence of neural foraminal narrowing or nerve root compression on this scan.
1. Postop (L5 right laminectomy) changes at the level of L5S1 as described above.2. Diffuse bulging of disc, L45.Comment: if clinically indicated Gad enhanced L spine MRI can be considered for further evaluation.