84 years Male (DOB:6/10/1932)Reason: Degenerative disk disease lumbar spine History: Lower back painPROVIDER/ATTENDING NAME: TARIQ MUSLIM MALIK TARIQ MUSLIM MALIK 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.At L5-S1 there is a disc bulge and disc desiccation at this level associated bilateral facet and ligamentum flavum hypertrophy. There is effacement of the fat at the lateral recess bilaterally but more on the right than the left. There is narrowing of the neural foramina with partial effacement of the fat surrounding the exiting nerve roots.At L4-5 there is some loss of disc space height, disc bulge and moderate to marked bilateral facet ligamentum flavum hypertrophy. There is mild anterior subluxation of L4 on L5. There is effacement of the fat at the lateral recess bilaterally. There is narrowing the spinal canal and crowding of the nerve roots within the thecal sac at this level. Overall there is a moderate to marked degree of spinal stenosis at this levelAt 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.There is a 46 mm cystic lesion present off the inferior pole of the right kidney. There is a 32 mm cystic lesion along the superior aspect of the right kidney. Both of these cystic lesions are only partially imaged on this exam.
1.There are degenerative changes present in the lower lumbar spine.2.There is a moderate to severe degree of spinal stenosis present at L4-5 related to disc disease and facet disease as well as a small degree of subluxation.3.There is encroachment of the nerve roots at the lateral recess bilaterally at L5-S1 but worse on the right side compared to the left. There is mild to moderate spinal stenosis at L5-S1.4.There are large cystic lesion along the right kidney. These are not completely imaged on this exam. Please refer to abdomen CT exam from 9/2/2015 for further comments