55 years Male (DOB:4/28/1960)Reason: lower back pain and LLE radiculopathy History: abovePROVIDER/ATTENDING NAME: MICHAEL J LEE MICHAEL J LEE 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 no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and diffuse disc bulge at this level associated with some ligamentum flavum hypertrophy and some mild facet hypertrophy. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L4-5 there is loss of disc space height, diffuse disc bulge and bilateral ligamentum flavum hypertrophy associated with partial effacement of the fat at the right lateral recess and some encroachment of the nerve roots of the right lateral recess. There is is some crowding of the nerve roots within the thecal sac at this level. The nerve roots appear to be adherent to the walls of the thecal sac. There is mild to moderate 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 loss of disc space height, diffuse disc bulge and disc desiccation associated with some ligamentum flavum hypertrophy. There is a disc extrusion present at this level with disc material extrudes behind the L4 vertebral body. This contributes significantly to the spinal stenosis at this level. There is narrowing of the spinal canal at this level and there is crowding of the nerve roots within the thecal sac. This suggests moderate spinal stenosis. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.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 are multilevel degenerative changes present in the lumbar spine with moderate spinal stenosis at L3-4 (where there is a large disk extrusion), mild to moderate spinal stenosis at L4-5 and encroachment of nerve roots at the right lateral recess at L4-5 due to degenerative changes.2.Nerve roots appear to adhere to the wall of the thecal sac in the lower lumbar spine. This may raise the question of arachnoiditis. Alternatively this could be a coincidental appearance and explained by the effect of the disc extrusion on the position of the nerve roots within the thecal sac. Please correlate patient's clinical history. If based on this evaluation further imaging is warranted, contrast enhanced MRI may be of benefit.