80 years Female (DOB:8/17/1935)Reason: history of lumbar fusion History: history of lumbar fusionPROVIDER/ATTENDING NAME: BEN-ZION ROITBERG BEN-ZION ROITBERG The patient is status post laminectomies at L1, L2, L3 and L4 and fusion using pedicle screws and interconnecting rods from L1 through L5. There is approximately 13 mm anterior subluxation of L4 and L5. There is T2 signal hyperintensity present along the perivertebral musculature. There is fatty replacement of the paraspinous musculature at L5 and at the level of the sacrum.The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation present at this level associated with a diffuse disc bulge, significant loss of disc space height and endplate reactive change which is high signal on T1. There is mild facet hypertrophy at this level.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space heights disc desiccation and anterior subluxation of L4 and L5 at this level. At L3-4 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height at this level. There is a fluid collection behind the thecal sac at this level measuring 11 x 26 mm axial dimensions and 27 x 14 mm sagittal dimensions. It is well-circumscribed. 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 mild posterior subluxation of L1 on L2. There is loss of disc space height and some endplate reactive changes which are hyperintense on T1.At T12-L1 there is loss of disc space height and disc desiccation and some mild compression along the anterior-inferior aspect of T12.There is a 56 mm cystic lesion along the superior pole of the left kidney. There is a 8 mm cyst along the upper portion of the right kidney. There is a 15 mm cyst along the inferior portion of the right kidney. There is a 28 mm cyst along the inferior aspect of the left kidney. There is a 15 mm cyst along the midportion of the left kidney.
1.The patient is status post lumbar spine surgery with multilevel laminectomies and posterior fusion using pedicle screws and interconnecting rods. There is no significant compromise to the spinal canal or exiting nerve roots on the current exam. 2.There are multilevel degenerative changes present in the lumbar spine without subluxation at L4-5 and lesser degree L1-23.Signal changes within the paraspinous musculature are present. This could represent edema from recent surgery or denervation atrophy.4.There is a fluid collection behind the thecal sac at the surgical site which is well-circumscribed.5.There are multiple renal cysts present measuring up to 5.6 cm in size.