66 years Male (DOB:12/31/1949)Reason: persistent back pain History: back painPROVIDER/ATTENDING NAME: MICHAEL J LEE MICHAEL J LEE Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is loss of disc space height, disc desiccation and a disc bulge. There is mild facet and ligamentum flavum hypertrophy at this level. There is partial effacement of the fat at the right lateral recess at this level with mild to moderate encroachment of the nerve roots at the right recess. There is minimal effacement of fat at the right lateral recess at this level.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation and a disc bulge at this level associated with mild to moderate bilateral facet and ligamentum flavum hypertrophy. There is 1 mm anterior subluxation of L4 on L5 present. There is partial effacement of the fat at the lateral recess on the left side into a lesser degree right side. There is mild to moderate encroachment of the nerve roots at the left lateral recess at this level. There is some mild encroachment of the nerve roots of the right lateral recess at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is mild loss of disc space height, diffuse disc bulge and disc desiccation associated with moderate ligamentum flavum hypertrophy and mild to moderate facet hypertrophy. There is effacement of the fat at the lateral recess bilaterally at this level but more on the left compared to the right side. There is encroachment of the nerve roots at the left lateral recess at this level. There is some mild encroachment of the nerve roots of the right lateral recess at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge at this level associated with disc desiccation and loss of disc space height. There are Schmorl's nodes present at this level. There is mild to moderate ligamentum flavum hypertrophy at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina. The right anterior lateral endplate osteophytes present this levelThere are multiple cysts present along the kidneys.
1.There are multilevel degenerative changes present in the lumbar spine associated with some encroachment of the nerve roots of the right lateral recess at L5-S1, the left lateral recess at L4-5 and the left lateral recesses at L3-4 as detailed above.2.There are multiple renal cysts present.