50 years Male (DOB:7/9/1966)Reason: disc herniation History: LLE painPROVIDER/ATTENDING NAME: JAMES MOON MOK JAMES MOON MOK 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.At L5-S1 there is no significant compromise to spinal canal. There is loss of disc space height and disc desiccation at this level. There is a broad-based right lateral recess disc extrusion at this level with disc material extending behind the adjacent endplates which encroaches on the nerve roots at the right lateral recess at this level. Disc material mildly displaces the nerve root the left lateral recess at this level. There is subtle effacement of the fat planes superficial to the right lamina of S1 and along the subcutaneous tissues behind the right perivertebral musculature which extends to the right lamina of L5.. There is associated T2 signal hyperintensity within the right posterior medial perivertebral musculature at this level. At L4-5 there is no significant compromise to spinal canal or neural foramina.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.
1.There is a right lateral recess disc extrusion present which encroaches on the nerve roots at the right lateral recess at L5-S1 (probably S1 nerve roots). The possibility of associated scar formation cannot be excluded. A contrast enhanced exam may help further assess this if clinically appropriate.2.Findings suggest status post right L5 laminotomy procedure.