Radiculopathy, lumbar region [M54.16], Reason for Study: ^Reason: stenosis? History: increasing L foot pain, s/p extensive surgery 2 years ago For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1.Redemonstration of posterior fusion status between L3 and L4 as well as L5 laminectomy and L45 and L5S1 anterior fusion.Previously shown operation site fluid collections especially at the level of L5 laminectomy site has been significantly decreased since prior scan [29.3mm (AP) x 21.7mm (CC) x 11.1mm (RL), was 5.6cm x 4.5cm]. The T2 images show multiple internal linear signal intensities which may indicate internal septae formation. The laminectomy site as well as adjacent muscle show enhancement including the peripheral aspect of the residual fluid signal intensity lesion. Soft tissue enhancement around the L3 and L4 pedicular screws are also seen, no significant interval change since prior scan.Rotational deformity of the L4, L5 and S1 vertebral bodies, unchanged since prior scan.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: broad based disc bulging central to left with disc dessication. No neuroforaminal narrowing or spinal stenosis, unchanged since prior scan. L1-L2: Diffuse bulging of disc which abuts thecal sac with bilateral ligamentum flavum thickening, unchanged since prior scan. L2-L3: Minimal facet hypertrophy, unchanged since prior scan. L3-L4: Broad based disc bulge toward left neural foramen, unchanged since prior scan. L4-L5: Broad based disc bulge toward left side lateral recess which abuts thecal sac, unchanged since prior scan. L5-S1: Redemonstration of bilateral laminectomy defects. Deformed L5 and S1 spinal canal and bilateral neural foramen are again seen, no significant interval change since prior scan.
1. Interval significant decrease of L5 laminectomy site fluid collection lesion size with evidence of internal septae formation.2. Multilevel degenerative and congenital alignment deformity are again seen, unchanged since prior scan.3. No evidence of instrumentation related unusual finding.