Diagnosis: Disturbance of skin sensation Pain in joint, pelvic region and thigh. Pain in limbClinical question: please r/o stenosis, disc disease, other pathologySigns and Symptoms: pain 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 an 11mm T1 hyperintense lesion at the superior and right aspect of the T11 vertebral body present.At L5-S1 there is mild disk dessication present. There is a disk bulge at this level associated with ligamentum flavum hypertrophy and partial effacement of the fat at the lateral recesses. There is mild encroachment of the exiting nerve roots within the neural foramina at this level.At L4-5 there is loss of disk space height disk dessication and a large right paramedian disk extrusion associated with encroachment of the nerve roots at the right lateral recess. There is bilateral facet and ligamentum flavum hypertrophy at this level. There is a right far lateral broad based disk protrusion at this level. There is moderate encroachment of the left exiting nerve roots within the neural foramen at this level. There is mild encroachment of the left exiting nerve roots at this level due to disk material and facet hypertrophy. There is mild to moderate encroachment of the nerve roots at the right lateral recess at this level due to facet and ligamentum hypertrophy and disk disease. There is slight anterior subluxation of L4 on L5 at this level.At L3-4 there is a diffuse disk bulge associated with mild facet and ligamentum hypertrophy. There is mild to moderate encroachment of the left exiting nerve roots at this level due to disk material and facet hypertrophy. Overall there is mild spinal stenosis at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a diffuse disk bulge and disk dessication associated with mild facet and ligamentum hypertrophy. At L1-2 there is no significant compromise to spinal canal or neural foramina. There is a diffuse disk bulge and disk dessication associated with mild facet and ligamentum hypertrophy. The right adrenal gland appears to be fairly large but is not entirely included on this exam.
1.There are multilevel degenerative changes present in the form of disk disease and facet disease throughout the lumbar spine which are worse at L4-5 where there is mild subluxation, a disk extrusion and a right far lateral protrusion resulting in mild to moderate spinal stenosis and encroachment of right exiting nerve roots and encroachment of the nerve roots at the right lateral recess.2.There is encroachment of the left exiting nerve roots at L3-4.3.The right adrenal gland appears large, however, it is not entirely included on this exam and not adequately evaluated. If there is clinical concern for adrenal gland disease additional imaging may be helpful. This is an incidental finding.4.An email with the above findings was sent to Dr Kanani and Dr Tao Xie.