Lumbago [724.2], Reason for Study: ^Reason: r/o DJD progression/ spinal cord compression History: lower back pain with radiation to left thigh For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is acute compression fracture of L2 vertebral body with about 20% of height loss.There is no definitive evidence of retropulsion of fracture fragment.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 theL1 level. Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: Mild bilateral ligamentum flavum thickening, no neuroforaminal narrowing or spinal stenosis. L2-L3: Diffuse bulging of disc, previously seen central to left disc protrusion is not shown on today's scan. Instead there is broad based diffuse bulging of disc toward left side foramen causing minimal neural foraminal narrowing but does not show any evidence of direct nerve root compression. L3-L4: Diffuse bulging of disc with bilateral ligamentum flavum thickening causing mild to moderate spinal canal stenosis. L4-L5: Diffuse bulging of disc, minimal spinal canal stenosis. Subchondrosclerosis of bilateral facet joint with the minimal thickening of ligamentum flavum. L5-S1: no neuroforaminal narrowing or spinal stenosis.
1. Acute compression fracture of L2 vertebral body with the 20% of height reduction.2. Degenerative spondylosis of L-spine.3. Retracted previously seen L23 disc protrusion with remained broad based disc bulging without evidence nerve root compression.Comment: if the back pain is clinically intolerable with conservative management, please contact neurointerventional radiology for percutaneous kyphoplasty if indicated. 