54 years Female (DOB:2/8/1962)Reason: Progressing numbness of L leg to groin, new-onset L leg weakness History: as abovePROVIDER/ATTENDING NAME: SHANNON K MARTIN AUDREY L. TANKSLEY Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. There is mild anterior subluxation of L4 and L5. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with mild hypertrophy. There is partial effacement of the fat at the left lateral recess at this level with mild encroachment of nerve roots. There is narrowing of the neural foramina bilaterally at this level with some encroachment of the left-sided exiting nerve roots.At L4-5 there is loss of disc space height, disc desiccation and endplate reactive change. Endplate reactive changes dark on T1 and bright on T2 STIR. There is associated effacement of the fat at the lateral recess bilaterally at this level and crowding of the nerve roots with moderate to severe spinal stenosis resulting. There is also narrowing of the neural foramina due to disc material bilaterally with encroachment of exiting nerve roots bilaterally. There is mild anterior subluxation of L4 and L5. There is marked bilateral facet and ligamentum flavum hypertrophy at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge present at this level associated with mild ligamentum flavum hypertrophy.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.
1.There is moderate to severe spinal stenosis associated bilateral encroachment of exiting nerve roots at L4-5 related to a combination of diffuse disc bulge, marked facet hypertrophy and subluxation.2.There are some mild to moderate encroachment of the nerve roots at the left lateral recess at L5-S1 and within the left neural foramen at L5-S1.