66-year-old female with low back pain, right calf pain. History of lumbar fusion. Evaluate for stenosis or abnormality. Examination is limited by significant hardware artifact spanning L2-L5. Five lumbar type vertebral bodies are presumed to be present. Alignment appears to be anatomic however this is obscured by hardware artifact. At T12-L1 there is disc desiccation with broad-based protrusion of disc abutting the thecal sac associated with moderate narrowing of the spinal canal this level. Spinal cord signal appears to be unremarkable at this level. There are Modic type II vertebral endplate changes at this level consistent with acute to subacute endplate degenerative changes. There is mild ligamentum flavum and facet hypertrophy. There is moderate left neural foraminal stenosis and mild-to-moderate right neural foraminal stenosis at this level.At L1-L2 the neural foramina cannot be evaluated. The spinal canal is also not well evaluated however there does not appear to be significant spinal canal stenosis.At L2-3 the neural foramina cannot be evaluated. The spinal canal is also not well evaluated however there does not appear to be significant spinal canal stenosis.At L3-L4 the neural foraminal and spinal canal cannot be evaluated. At L4-L5 the neural foraminal and spinal canal cannot be evaluated.L5-S1 the neural foramina and spinal canal cannot be evaluated.No abnormal paraspinal mass lesions are identified.
1. Exam is markedly limited by artifact related to spinal fusion instrumentation which obscures evaluation of the neural foramina and spinal canal most prominent at mid lumbar level to the lumbosacral spine. At L1-L2 and L2-L3 the spinal canal is not well evaluated however there does not appear to be significant spinal canal stenosis.2. Worsening degenerative changes at the T12-L1 level demonstrating disc desiccation and broad-based protrusion of disc abutting the thecal sac associated with moderate narrowing of the spinal canal at this level. The spinal cord signal appears to be unremarkable at this level. There are new Modic type II vertebral endplate changes at this level consistent with acute to subacute endplate degenerative changes. There is moderate left neural foraminal stenosis and mild-to-moderate right neural foraminal stenosis at this level.