Spinal stenosis, lumbar region, with neurogenic claudication [724.03], Reason for Study: ^Reason: eval for epidural hematoma History: s/p spinal fusion For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There are evidence of external fixation using rods and screws from L2 to L5 with bilateral total laminectomies from L4 to L5.There are also interbody spacer in the L23 and L34 disc spaces.The L4 and L5 vertebral bodies appears to be fused.At the level of L34, there is disc-osteophyte complex which shows broad based central to left protrusion and abuts thecal sac.There is also bony structure on the left side of the left L34 lateral recess indicating left L3 inferior articular process of facet joint. There is no definitive evidence of fluid collection or blood product at the left lateral recess area of L34 disc space on this MRI, though those possibilities cannot be excluded completely due to adjacent screw related metallic artifacts.On the right side lateral recess of the L34, there is mild foraminal stenosis. At the level of L23, bilateral mild to moderate foraminal stenosis are seen.Conus medullaris terminate at the level of L12 and the signal intensity of the spinal cord appears to be normal.There is subcutaneous fluid collection with air-fluid level which corresponds to postoperative changes.
1. External fixation using rods and screws from L2 to L5 with interbody spacer at L23 and L34 as described above.2. Left side lateral recess stenosis of L34 level likely related to both disc-osteophyte complex of L34 disc and inferior articular process of facet joint of L3. The likelihood of epidural blood products around the level of the L34 disc space is slim.3. Other postoperative changes do not show significant interval change since prior CT scan.