Diagnosis: Other intervertebral disc degeneration, lumbosacral regionClinical question: low back pain radiating down her legs, eval for stenosisSigns and Symptoms: low back pain Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild loss of disc space height, disc desiccation and a mild disc bulge at this level. There is mild facet hypertrophy present at this level.At L4-5 there is loss of disc space height, disc desiccation as well as a broad-based right lateral recess disc protrusion which effaces the fat at the right lateral recess and partially effaces the fat at the left lateral recess. There is mild to moderate facet ligamentum flavum hypertrophy at this level associated with a subtle anterior subluxation of L4 and L5. There is mild encroachment of the nerve roots at the right lateral recess at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is a small right far lateral disc protrusion present at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a broad-based left far lateral disc protrusion at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.There appears to be enlargement of the right common bile duct where measures up to 8 mm in diameter.
1.There are degenerative changes present in the lumbar spine which are worse at L4-5 where there is encroachment of the nerve roots of the right lateral recess due to a disc protrusion.2.There appears to be enlargement of the right common bile duct. This is not entirely imaged on this exam. If clinically appropriate correlation with clinical history and additional imaging may be of benefit to further evaluate this.3.An email was sent to Dr Omar Qureshi regarding the above findings. Pager 3153 was paged at the time of this dictation.