Diagnosis: Lumbago with sciatica, left sideClinical question: s/p lumbar fusion, new onset left leg pain/low back painSigns and Symptoms: s/p lumbar fusion, new onset left leg pain/low back pain 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. No abnormal enhancing lesions are present in the spinal cord or nerve roots.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is a central disc protrusion present at this level which impresses on the ventral aspect of thecal sac. It is associated with adjacent contrast enhancement which extends into the adjacent fat planes of the left lateral recess. The patient is status post left hemilaminectomy at this level. There is enhancement along the left perivertebral soft tissues. There is a ring-enhancing lesion present within the left laminectomy site measuring 16 x 9 mm axial dimensions. At L4-5 there is no significant compromise to spinal canal or neural foramina. There is a right far lateral disc protrusion present at this level which mildly encroaches on the right-sided exiting nerve root as it exits the neural foramen. There is diffuse disc bulge and mild ligamentum flavum hypertrophy present at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is a 14 x 8 mm axial dimension enhancing focus present just lateral to the left neural foramen at this level. There is a left far lateral disc protrusion present at this level.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 is a mass present along the right kidney which is exophytic to the right kidney and measures 55 x 47 mm axial dimensions. It is associated with some heterogeneous enhancement following gadolinium and administration. It is heterogeneous on T2. It is hypointense on T1 but somewhat heterogeneous on T1 as well.
1.There is a mass present along the right kidney. The possibility this represents a neoplasm cannot be excluded. Current exam does not include the entire mass. If clinically appropriate additional imaging may be of benefit.2.Findings raise the question of a abscess at the left hemilaminectomy site at the L5-S1 level. 3.There is a small disc protrusion associated with the inflammatory changes consistent with scar formation at the left lateral recess of L5-S1 affecting the nerve roots at the left lateral recess at L5-S1.4.There is an inflammatory lesion present associated with the left-sided exiting nerve root at L3-4 along the lateral aspect of the neural foramen which is likely related to recent microdiscectomy performed at this site and may represent scar tissue for example. Please correlate with patient's clinical symptoms.5.At the time of this dictation the above findings were discussed with Dr. Mok.6.There is a right far lateral disc protrusion present mildly affecting the right-sided exiting nerve root at L4-5. This was also present on the prior MRI of the lumbar spine from January 2014 .