79 years Female (DOB:11/9/1936)Reason: Evaluate for spinal stenosis vs neural foraminal stenosis History: Decreased sensation right lower extremity, fallsPROVIDER/ATTENDING NAME: SUSAN B. GLICK SUSAN B. GLICK 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 some loss of disc space height, disc desiccation and diffuse disc bulge associated with some mild displacement of the nerve roots at the right lateral recess. The fat at the lateral recess is not effaced bilaterally. There is some mild facet hypertrophy present at this level. There is endplate reactive changes which is hyperintense on T1 at this level. There is some mild narrowing of the neural foramina as a result of the disc bulge. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat. The patient is status post right hemilaminotomy at this level.At L4-5 there is loss of disc space height, a mild disc bulge and bilateral facet hypertrophy with fusion across the facet joints. There is mild anterior subluxation of L4 on L5. There are some endplate reactive changes present this level which are predominantly high signal on T1, however, there is some T2 signal hyperintensity adjacent to the disc at the inferior endplate of L4 on the left lateral aspect of the endplate. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L3-4 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with some facet hypertrophy and mild anterior subluxation of L3 on L4. There is narrowing of the thecal sac at this level with some crowding of the nerve roots and overall a moderate degree of spinal stenosis. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge at this level as well as some disc desiccation.At L1-2 there is no significant compromise to spinal canal or neural foramina.
There are degenerative changes present in the lumbar spine with moderate spinal stenosis at L3-4.