History of lumbar discectomy, evaluate for abnormality, disc herniation. Recurrent pain down left leg. Right calf numbness and toe cramping. Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. Alignment is grossly maintained. Bone marrow signal is benign. The conus medullaris is normal in position. Postsurgical changes of prior discectomy at L4-L5 with small laminotomies are noted.Lumbar spinal canal appears mildly narrowed congenitally with superimposed degenerative changes, as described below. L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: There is mild disc bulge with central disc protrusion which effaces the ventral thecal sac and lateral recesses right greater than left. There is bilateral facet arthropathy and ligamentum flavum thickening. There is mild central canal stenosis. No significant neural foraminal narrowing.L3-L4: Mild disc bulge, ligamentum flavum thickening, and facet arthropathy contribute to mild to moderate spinal canal stenosis at this level. Minimal bilateral neural foraminal narrowing.L4-L5: Mild disc bulge without evidence of recurrent disc herniation at this level. Moderate bilateral facet arthropathy is noted. There is mild left neural foraminal narrowing and minimal right neural foraminal narrowing. No significant spinal canal narrowing, markedly improved since prior.L5-S1: Mild disc bulge, ligament of flavum thickening, and facet arthropathy resulting in mild central spinal canal stenosis. There is mild left neural foraminal narrowing and minimal right neural foraminal narrowing.Paraspinous soft tissues demonstrate postsurgical changes in the posterior paraspinous soft tissues at L4-L5 but otherwise unremarkable.
1. Postsurgical changes in the lumbar spine at L4-L5 without findings to suggest recurrent disc herniation or residual stenosis at this level. 2. There appears to be mild congenital narrowing of the lumbar spine with superimposed degenerative changes with mild to moderate spinal canal stenosis at L2-L3 (with disc extrusion) and at L3-L4. Minimal to mild multilevel neural foraminal narrowing. No high-grade spinal canal or high-grade neural foraminal stenosis is appreciated at any level.