69 years Female (DOB:5/18/1947)Reason: low back pain History: low back painPROVIDER/ATTENDING NAME: SERVICES ANCILLARY SERVICES ANCILLARY 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. Incidental note is made of a perineural cyst in the sacral hiatus on the left side at the level of S2 measuring approximately 16 x 10 mm sagittal dimensions.At L5-S1 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with bilateral facet hypertrophy. There is effacement of the fat at the right lateral recess and partial effacement of the fat at the left lateral recess. There is encroachment of the nerve roots of the right lateral recess level. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L4-5 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with some ligamentum flavum hypertrophy. There is effacement of the fat at the lateral recesses bilaterally this level and some encroachment of the nerve roots at the lateral recesses. Encroachment of the nerve roots at the lateral recesses worse on the right than the left side at this level.. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L3-4 there is loss of disc space height, disc desiccation and Schmorl's nodes associated with the disc bulge and ligamentum flavum and facet hypertrophy. There is no significant compromise to spinal canal or neural foramina at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge and ligamentum flavum hypertrophy at this level associated with some loss of disc space height and disc desiccation.At L1-2 there is no significant compromise to spinal canal or neural foramina. There is facet hypertrophy at this level.On sagittal imaging at the T10-T11 level there appears to be a disc bulge associated with ligamentum flavum hypertrophy and findings are suspicious for but not confirmatory for spinal stenosis.
1.There are degenerative changes present in the lumbar spine with encroachment of the nerve roots at the right lateral recess at L5-S1 and L4-5 as detailed above. There is a mild degree of spinal stenosis at L4-5.2.Findings raise the question of spinal stenosis at T10-T11 which is not entirely included on this exam. If clinically appropriate additional imaging of the thoracic spine may help evaluate this further.