65 years Male (DOB:9/17/1950)Reason: re-evaluate chronic lumbar stenosis, s/p 2 laminectomies History: as abovePROVIDER/ATTENDING NAME: HELENE G. RUBEIZ HELENE G. RUBEIZ 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. There is a T1 hyperintense lesion present within the L2 vertebral body on the right side which measures 14 mm in diameter and most likely represents a vertebral body hemangioma.Patient is status post laminectomy at L5-S1 and L4-5At L5-S1 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with endplate reactive changes. Endplate reactive changes are low signal on T1 and T2. There is effacement of the fat at the lateral recess bilaterally at this level which was also present on the prior exam and does not appear to have changed substantially. There is partial effacement of the fat surrounding the exiting nerve roots bilaterally associated with some encroachment of the exiting nerve roots within the neural foramina. Encroachment of exiting nerve roots is worse on the left compared to the right side.At L4-5 there is a diffuse disc bulge present, loss of disc space height and disc desiccation and endplate reactive change. Endplate reactive changes low signal on inversion recovery images and high signal on T1. There is effacement of the fat at the lateral recess bilaterally at this level. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat. Overall there is no substantial change compared to the prior exam.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is some loss of disc space height and disc desiccation at this levelAt L2-3 there is no significant compromise to spinal canal or neural foramina. There is right-sided facet hypertrophy at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.There is a cyst present along the right kidney measuring 44 mm in diameter is unchanged compared to the prior exam to extent of visualization. It is not entirely included on this exam. Left-sided renal cystic lesions were also present on the prior exam which are not entirely included on the current exam.
1.Overall there is no significant change compared the prior exam.2.The patient status post lumbar spine surgery at L4-5 and L5-S1 where there is some encroachment of the nerve roots at the lateral recesses.3.There is encroachment of exiting nerve roots bilaterally at L5-S1 appears slightly worse on the left side compared to the right side. This is stable compared to the prior exam.4.The patient's renal cystic lesions are redemonstrated and although they appear similar to the prior exam they are not entirely included on this exam