61 years Female (DOB:2/21/1954)Reason: evaluate for mets History: pain. shootingReferring Attending: SUSAN HONG 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. No abnormal enhancing lesions are appreciated in the lumbar spine.At L5-S1 there is loss of disc space height, disc desiccation and a broad-based left lateral recess disc protrusion which impresses on the nerve roots of the left lateral recess. The exiting nerve roots within the neural foramina are surrounded by fat. There is partial effacement of the fat surrounding the left-sided exiting nerve roots within the neural foramen.At L4-5 there is marked loss of disc space height, diffuse disc bulge and partial effacement of fat at the lateral recess bilaterally.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height and disc desiccation at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height and disc desiccation at this level. There is a left far lateral disc protrusion present at this level which displaces the left-sided exiting nerve after it exits foramen.At L1-2 there is no significant compromise to spinal canal or neural foramina.The uterus appears enlarged and heterogeneous with multiple T2 hypointense lesions.
1.There is no evidence for metastases to the lumbar spine.2.There are multilevel degenerative changes in the lumbar spine worse at L5-S1 where there is some mild encroachment of the nerve roots of the left lateral recess and the left neural foramen due to a broad-based disc protrusion. There is a left far lateral disc protrusion at L2-3 displacing the left-sided exiting nerve root after it exits the neural foramen.3.Multiple uterine fibroids are suspected. Please correlate with clinical history and exam.