Lumbago with sciatica, unspecified side [M54.40] / Pain in right hip [M25.551] / Muscle weakness (generalized) [M62.81], Reason for Study: ^Reason: evaluate for compression, hx of sever DDD with RLE weakness History: low back pain with radiation down RLE For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is large soft tissue mass replacing normal fatty marrow of L5 and sacrum with extension toward spinal canal. The mass lesion shows inhomogenous enhancement with evidence of extension toward neuroforamen and spinal canal. The bladder appears to be significantly enlarged, thus considering the mass location and its extent, cauda equina syndrome needs to be considered and excluded.There is normal lumbar lordosis. The spine alignment is anatomic. The vertebral body height is preserved. The signal of the visualized cord is normal.The conus medullaris terminates at the T12-L1 level. Degenerative changes are specified by the intervertebral level as follows: T12-L1: disc dessication, no neuroforaminal narrowing or spinal stenosis. L1-L2: disc dessication, no neuroforaminal narrowing or spinal stenosis. L2-L3: disc dessication, diffuse bulging of disc, no neuroforaminal narrowing. Minimal spinal canal stenosis. L3-L4: disc dessication, diffuse bulging of disc, mild to moderate spinal stenosis. L4-L5: disc dessication, diffuse bulging of disc, moderate to severe spinal stenosis. L5-S1: inferior aspect of the L5 vertebral body shows tumor involvement with spinal canal at the level of L5S1 appears to be filled with soft tissue mass indicating spinal canal involvement by the mass.
1. Inhomogeneously enhancing soft tissue mass replacing normal fatty marrow signal intensity of the L5 and sacral vertebral body with evidence of spinal canal and bilateral sacral neuroforamen. Most likely etiology of the soft tissue mass is metastatic lesion.2. Multilevel various degree degenerative changes of lumbar spine. Especially at the level of L45, there is moderate to severe spinal stenosis.Comment: Due to obliteration of the spinal canal and bilateral sacral neuroforamen associated with enlarged bladder, Joan Bigane ANP was contacted at the time of this dictation.I have informed her that the patient has large soft tissue mass at the sacrum and possible development of cauda equina syndrome due to the mass. 