65 years Female (DOB:1/7/1951)Reason: lower back pain, rule adjacent segment disease and possible stenosis History: abovePROVIDER/ATTENDING NAME: MICHAEL J LEE MICHAEL J LEE 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.The patient is status post laminectomy and posterior and anterior fusion at L4-5 with pedicle screws and interconnecting rods at these levels as well as disc spacer. There appears to be osseous bridging at the L4-5 disc level.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is facet hypertrophy present at this level which is worse on the left compared to the right side which has only slightly progressed since the prior exam from 2006.At L4-5 there is no significant compromise to spinal canal or neural foramina.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is mild ligamentum flavum hypertrophy at this level which is stable. There is a diffuse disc bulge present at this level which has developed since the prior exam mildly narrowing the neural foramina bilaterally. There is associated disc desiccation.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height at this level which has developed since the prior exam which is associated with endplate reactive changes and Schmorl's nodes as well as some mild T2 signal hyperintensity adjacent to the endplates within the L2 and L3 vertebral bodies.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.The patient is status post L4-5 surgery. There is no significant compromise to the spinal canal or neural foramina. Since the previous exam degenerative disc changes have progressed at L2-3 and L3-4 with some findings that suggest subacute inflammatory changes at L2-3. Although there is some further narrowing of the neural foramina at these levels the exiting nerve roots are not significantly compromised.