70 years Female (DOB:8/29/1945)Reason: Patient with left back and hip pain with sciatica. Please identify lumbar spine pathology. History: Patient with left back and hip pain with sciatica.PROVIDER/ATTENDING NAME: ELBERT S. HUANG ELBERT S. HUANG 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 bilateral facet hypertrophy of moderate degree associated with ligamentum flavum hypertrophy. The fat at the lateral recess is not effaced on either side. The right-sided exiting nerve root within the neural foramen appears thickened at this level there is a cystic structure at the lateral most aspects of the neural foramen associated with the facet joint which encroaches on the right-sided exiting nerve root within the neural foramen.At L4-5 there is loss of disc space height, disc desiccation, diffuse disc bulge and bilateral facet and ligamentum flavum hypertrophy associated with mild anterior subluxation of L4 on L5 and narrowing of the spinal canal with crowding of the nerve roots within the thecal sac and effacement of the fat at the lateral recess. Overall there is a moderate to severe degree of spinal stenosis at this level. The neural foramina are narrowed bilaterally at this level but worse on the left lung compared to the right side and there is encroachment of the exiting nerve roots bilaterally within the neural foramina but worse on the left than the right side.At L3-4 there is loss of disc space height, disc desiccation and a diffuse disc bulge associated with ligamentum flavum and facet hypertrophy. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat. There is mild encroachment of the nerve roots of the left lateral recess at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a disc bulge present at this level associated disc desiccation and mild loss of disc space height.At L1-2 there is no significant compromise to spinal canal or neural foramina.There are multiple small cysts present within the kidneys. In the larger one along the left kidney which is not well demonstrated on this exam but measures approximately 4 to 5 cm in size.At T10-11 there is obliteration of the disc space height. There appears to be a disc protrusion at that level but does not appear to compromise to spinal cord.
1.There are multilevel degenerative changes present in the lower lumbar spine with moderate to severe degree of spinal stenosis at L4-5 related to disc disease and facet disease as well as subluxation. 2.There is encroachment of exiting nerve roots within the right neural foramen at L5-S1 due to right-sided facet disease and a cystic lesion adjacent to the right facet joint.3.There is encroachment of exiting nerve roots within the right neural foramen at bilaterally at L4-5 related to degenerative changes4.There are degenerative changes also present in the thoracic spine which are not well documented on this exam.