Questioning back pain. Left-sided radiculopathy. Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. There is dextroscoliosis of the upper lumbar spine and mild levocurvature of the lower lumbar spine which was also present on prior abdominal CT. There is also minimal retrolisthesis of L1 on L2. There is extensive low T1 signal involving the left aspect of the sacrum with also increased STIR hyperintensity on the sagittal STIR sequence which partially includes the pelvis. Axial T2 images demonstrate linear areas of T2 signal hyperintensity suspicious for insufficiency fracture. The conus medullaris is normal in position.Distended gallbladder with gallstones, cystic lesion involving the pancreatic head, and renal cysts are again seen and better evaluated on prior dedicated abdominal CT. Multilevel degenerative changes are seen, as described below:L1-L2: Mild disc bulge and bilateral facet arthropathy. No spinal canal or neural foraminal stenosis.L2-L3: Mild disc bulge and moderate bilateral facet arthropathy. Minimal narrowing of the spinal canal. There is mild left neural foraminal narrowing. Right neural foramen is patent.L3-L4: Mild disc bulge and moderate facet arthropathy, particularly on the right. There is mild spinal canal stenosis. There is mild narrowing of the left neural foramen. Right neural foramen is patent.L4-L5: Minimal disc bulge and moderate facet arthropathy. No significant spinal canal or neural foraminal stenosis.L5-S1: Minimal disc bulge and advanced bilateral facet arthropathy. There is no significant spinal canal stenosis. There is mild to moderate right-sided neural foraminal stenosis. Left neural foramen is patent.
1. Multilevel degenerative changes throughout the lumbar spine with scoliosis. There is no high-grade spinal canal or high-grade neural foraminal stenosis at any level. Mild or mild to moderate degrees of stenoses as detailed above.2. There is diffuse low T1 and increased STIR signal throughout the left aspect of the sacrum. There are linear areas of high T2 signal within this region likely representing sacral insufficiency fracture. Pathologic fracture is not excluded and would suggest follow-up MR pelvis evaluation with contrast.Dr. Ali discussed findings with Tanya Roberts (Dr. Datta's nurse) at 1315 hrs on 11/17/2016. 