Radicular pain in the right lower extremity, assess for lumbar radiculopathy Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. There is minimal retrolisthesis of L2 on L3 and minimal anterolisthesis of L4 and L5. There is severe loss of disc height at the L2-L3 and L4-L5 levels and to a lesser degree at L3-L4. Edematous endplate changes are seen at the L2-L3 and L5-S1 levels. There is also mild edema involving the L3-L4 disc space most likely on a degenerative basis. Bone marrow signal is benign. The conus medullaris is normal in position.Multilevel degenerative changes are seen, as described below:L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: Disc bulge and endplate osteophytes, ligamentum flavum thickening, and bilateral facet arthropathy result in mild to moderate spinal canal stenosis. There is moderate right and mild to moderate left neural foraminal stenosis.L3-L4: Disc bulge, facet arthropathy, ligamentum flavum thickening with minimal spinal canal stenosis. There is mild right and moderate left neural foraminal stenosis. Suggestion of prior surgical laminotomy.L4-L5: Disc bulge, facet arthropathy, and ligamentum flavum thickening. There is no significant spinal canal stenosis. There is moderate right and moderate to severe left neural foraminal stenosis. Suggestion of prior surgical laminotomy.L5-S1: There is soft tissue measuring 11 x 10 mm with low T1 and low T2 signal dorsal to the inferior right L5 vertebral body suspected to represent extruded disc material versus granulation tissue, best seen on series 6 axial T2 image 35. There is associated effacement of the right lateral recess where there may be impingement of the right descending S1 nerve root. There is mild disc bulge, ligamentum flavum thickening, and bilateral facet arthropathy. There is no significant central canal stenosis. There is moderate right and mild to moderate left neural foraminal stenosis.There is mild atrophy involving the paraspinous musculature. Moderate degenerative changes involving the sacroiliac joints also noted.
1. Moderate degenerative changes throughout the lumbar spine. 2. There is an 11 x 10 mm soft tissue dorsal to the inferior right L5 vertebral body which may represent extruded disc material versus granulation tissue(series 6 axial T2 image 35); postcontrast images would be helpful to differentiate (also may correlate with prior records if prior surgery involved the L5-S1 level). There is associated effacement of the right lateral recess where there may be impingement of the right descending S1 nerve root. 3. There is mild to moderate spinal canal stenosis at L2-L3. There is also multilevel neural foraminal stenosis bilaterally (on the right at the L2-L3, L4-L5, and L5-S1 levels). Please see details above.