Female, 59 years old, with left buttock and back pain, and left lower extremity paresthesias. Alignment is anatomic. Vertebral body heights are preserved. Degenerative endplate irregularity is seen at L5-S1. No worrisome marrow replacement is detected.The visualized distal spinal cord, conus and cauda equina are within normal limits.Mild loss of disc T2 signal affects the lower lumbar levels. The L5-S1 disc demonstrates moderate loss of height. Additional level specific findings are as follows:L1-2: Unremarkable. L2-3: Mild laterally bulging disc. No spinal canal stenosis. Mild bilateral foraminal narrowing. L3-4: Mild facet hypertrophy and ligamentum flavum thickening. Mild laterally bulging disc. No significant spinal canal stenosis. Mild bilateral foraminal narrowing. L4-5: Moderate facet hypertrophy and ligamentum flavum thickening. Bulging disc. Mild spinal canal narrowing. Mild bilateral foraminal narrowing. L5-S1: Mild facet hypertrophy and ligamentum flavum thickening. Bulging disc. No significant spinal canal. Moderate left and mild right foraminal narrowing. A large quantity of intraperitoneal fluid is partially visualized in the pelvis. In addition, the right kidney is somewhat larger than the left and demonstrates mild heterogeneous signal characteristics, though this could be related to imaging artifact.
1. Multilevel degenerative disc disease is seen. At L5-S1, there is moderate loss of disc height, and although no significant spinal canal stenosis is seen, the left neural foramen is moderately narrowed.2. Incidental note is made of significant intraperitoneal pelvic fluid. The right kidney is also somewhat larger than the left with possible heterogeneous signal characteristics suggesting edema, though this could be artifactual. Dedicated abdominal imaging is suggested to better assess these findings. Findings were communicated to Dr. Schipper via email on 10/24/15 at 3:35 PM, and to Dr. Landy, orthopedic surgery resident on call, via phone on 10/24/15 at 3:45 PM. 