81 years Male (DOB:3/5/1935)Reason: assess for stenosis History: history of lumbar decompression in April, still having leg and back painPROVIDER/ATTENDING NAME: BEN-ZION ROITBERG BEN-ZION ROITBERG 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.There is T2 signal hyperintensity present along the superior anterior aspect of the L4 vertebral body adjacent to the endplates and eccentric to the right side. This may represent subacute inflammatory change.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild facet hypertrophy present at this level.At L4-5 there is a diffuse disc bulge present associated with loss of disc space height, disc desiccation and bilateral facet and ligamentum flavum hypertrophy. There is mild anterior subluxation of L4 and L5. The patient is status post right-sided hemilaminotomy at this level. There is effacement of the fat at the lateral recess bilaterally at this level but worse in the right compared to the left side. Compared to the prior exam there is no nerve root crowding on the current exam when compared to the prior. There is narrowing of the neural foramina bilaterally at this level. The nerve root exiting the left neural foramen are surrounded by fat whereas the right-sided exiting nerve root is encroached upon by a combination of facet hypertrophy and disc material.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.There are large cysts present along the kidneys bilaterally which were also present on the prior exam and do not appear to have changed severe not entirely included on this exam in the assessment of their size cannot be adequately done on this exam.
1.Since the prior examination the patient is undergone lumbar spine surgery at L4-5 there is no significant spinal stenosis at this level. Currently however, there is encroachment of the nerve roots within the right neural foramen and at the right lateral recess at this level as a result of disc disease and facet disease. A contrast enhanced exam may help differentiate scar from disc protrusion.2.Some subacute inflammatory changes are present along the anterior superior aspect of the L4 vertebral body eccentric towards the right side.3.Multiple large renal cystic lesions are not completely evaluated on this exam. There are present on prior exams and to the extent of visualization have not changed significantly