58 years Male (DOB:7/30/1958)Reason: back pain History: back painPROVIDER/ATTENDING NAME: RANIER T GULOY MAGDALENA ANITESCU 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. There is a levocurvature present to the lumbar spine which is centered at approximately L3 there is mild left lateral translation of L3 under L2..There appears to be tubing which enters between the L4 and L5 spinous processes into the thecal sac. The upper extent of the tubing is not included on this exam.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is a right paramedian disc protrusion present at this level which mildly encroaches on the nerve roots of the right lateral recess. There is bilateral facet hypertrophy at this level which is worse on the right compared to the left side. There is loss of disc space height, disc desiccation and minimal anterior subluxation of L5 on S1At L4-5 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and a disc bulge at this level. There is mild ligamentum flavum hypertrophy present.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and a minor disc bulge at this level. There is a right far lateral disc protrusion present at this level which displaces the right-sided exiting nerve roots.. There is some partial effacement of the fat at the right lateral recess with mild encroachment upon nerve roots at the right lateral recess.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is some loss of disc space height, disc desiccation and a right far lateral broad-based disc protrusion at this level. This right far lateral disc protrusion displaces the right-sided exiting nerve roots and is associated with some partial effacement of fat at the right lateral recess.At L1-2 there is no significant compromise to spinal canal or neural foramina.The renal pelvis and ureter are dilated bilaterally. The patient has known renal stents placed in the past.There is a large presacral mass present which is not completely evaluated on this exam.
1.There are multilevel degenerative changes present lumbar spine which is associated with a levocurvature to the lumbar spine and some mild degrees of translation and subluxation. There are far lateral disc protrusion present on the right-sided L2-3 and L3-4 with some mild nerve root displacements at these levels.2.There is a large presacral mass present which is not completely evaluated on this exam. Please refer to the patient's prior CT scans for further comments3.There is a drainage tube present within the thecal sac anteriorly at L4-5. Please correlate clinical history.4.Hydroureter and hydronephrosis. The patient is known to have renal stents please correlate with clinical history. CT of the abdomen may help further evaluate this if clinically appropriate.