Low back pain, leg numbness, hip weakness. Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. Minimal L2 on L3 retrolisthesis. Alignment is otherwise maintained. Bone marrow signal is benign. The conus medullaris is normal in position.Sagittal images demonstrate an epidural collection measuring at least 12 mm in the AP dimension and at least 4 cm in the craniocaudal dimension and extending outside of the field-of-view. This lesion is not well evaluated, but there appears to be effacement of the dorsal thecal sac. This collection demonstrates predominantly fluid density with possible low T2 signal inferiorly.Multilevel degenerative changes are seen, as described below:L1-L2: There is dorsal annular fissure with small left paracentral protrusion. No significant spinal canal or neural foraminal stenosis at this level.L2-L3: There is loss of disc height, associated endplate marrow signal changes, and mild diffuse disc bulge. There is no significant spinal canal stenosis. There is minimal bilateral neural foraminal narrowing.L3-L4: Minimal disc bulge. No spinal canal or neural foraminal stenosis.L4-L5: Minimal disc bulge. Minimal left neural foraminal narrowing. No spinal canal or right neural foraminal stenosis.L5-S1: Minimal disc bulge. No spinal canal or neural foraminal stenosis.There is mild facet arthropathy in the lumbar spine, relatively worse at L4-L5 and L5-S1. Small perineural cysts are incidentally seen at the S2 level. Paraspinous soft tissues are within normal limits.
1. Mild degenerative changes in the lumbar spine as detailed above without significant spinal canal or neural foraminal stenosis at any level.2. There is an epidural collection in the lower thoracic spine which is seen on the sagittal images and not included on the axial lumbar spine images. There appears to be at least mild narrowing of the thecal sac posteriorly. Recommend dedicated thoracic spine MRI for better evaluation.Findings were communicated to Dr. Roitberg at 1230 pm on 6/16/2015.