62 years Male (DOB:9/1/1954)Reason: eval lumbar spine and foramen History: lower back pain with sciatica, worsening over past 6 yrs and prev failed LESI's and physical therapyPROVIDER/ATTENDING NAME: TARIQ MUSLIM MALIK TARIQ MUSLIM MALIK 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.At L5-S1 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with narrowing of the neural foramina bilaterally and partial effacement of the fat surrounding the exiting nerve roots. There is effacement of the fat at the left lateral recess at this level with some encroachment of the nerve root at the left lateral recess. There is also partial effacement of the fat at the right lateral recess at this level. There is mild facet and ligamentum flavum hypertrophy at this level.At L4-5 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with bilateral facet and ligamentum flavum hypertrophy as well as translation thecal sac with effacement of the spinal fluid within the thecal sac at the nerve roots. There is moderate to severe spinal stenosis present at this level. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is a mild disc bulge at this level associated with some mild disc desiccation and 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.
There are degenerative changes present in the lumbar spine worse at L4-5 and L5-S1 where there is moderate to severe spinal stenosis at L4-5 and encroachment of the nerve roots at the left lateral recess at L5-S1.