Bilateral lower extremity weakness and numbness. Pain down posterior thighs. Unable to walk greater than 100 feet, must sit to have symptoms settle down. History of lumbar fusion at outside hospital in 2013, L3-S1. Starting to have same symptoms. Need to evaluate for stenosis above fusion or fusion breakdown. Five lumbar type vertebral bodies are presumed to be present. Again seen are postsurgical changes of posterior lumbar fusion from L3 through S1. Laminectomies are evident at L4, L5, and partially at L3. Hardware including loosening involving the bilateral L3 and right S1 screws is better appreciated on recent CT.Vertebral body heights are within normal limits. There is grade 1 anterolisthesis of L3 on L4; alignment is otherwise maintained. Bone marrow signal is benign. The conus medullaris is normal in position. Small Schmorl's node is seen involving the inferior endplate of L2Multilevel degenerative changes are seen, as described below:L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: There is moderate degree of spinal canal stenosis related to combination of disc bulge, bilateral facet arthropathy, and epidural fat which is predominantly in the lateral aspects of the spinal canal. There is also mild to moderate bilateral neural foraminal stenosis.L3-L4: There is moderate degree of spinal canal stenosis just above the level of the laminectomy related to combination of grade 1 anterolisthesis with disc uncovering, facet arthropathy, ligamentum flavum thickening. There is moderate bilateral neural foraminal stenosis.L4-L5: Spinal canal is well decompressed. There is moderate right-sided neural foraminal stenosis, with prominent endplate osteophytes more apparent on recent CT. Left neural foramen is grossly patent.L5-S1: Spinal canal is well decompressed. There is mild to moderate bilateral neural foraminal stenosis, not well assessed due to hardware.Aside from postsurgical changes, paraspinous soft tissues are grossly unremarkable.
1. Postsurgical changes of L3-S1 posterior fusion with loosening involving the bilateral L3 and right S1 screws better demonstrated on recent CT.2. There is moderate spinal canal stenosis at the L2-L3 level as well as at the L3-L4 level, just above the laminectomy. There is also multilevel neural foraminal stenosis including the bilateral L2-L3, L3-L4, L5-S1 and right L4-L5 levels. Please see details above.