79 years Female (DOB:4/8/1936)Reason: low back pain with compression fracture- healed or not? History: low back painPROVIDER/ATTENDING NAME: MICHAEL J LEE MICHAEL J LEE Five lumbar type vertebral bodies are presumed to be present . The conus medullaris on sagittal imaging is grossly intact. There is 30% loss of height of the L5 vertebral body which is new since the prior exam. There is some associated T1 and T2 signal hyperintensity but predominantly T1 hyperintensity. There is redemonstration of a mild L1 compression fracture.At L5-S1 there is no significant compromise to spinal canal or neural foramina.At L4-5 there is moderate bilateral facet hypertrophy present associated with a diffuse disc bulge. There is effacement of spinal fluid surrounding the nerve roots within the thecal sac. There is ligamentum flavum hypertrophy present. There is moderate spinal stenosis present. This has progressed since the prior examAt L3-4 there is disc desiccation and a disc bulge associated with posterior ligamentous hypertrophy at this level. There is effacement of fluid surrounding the nerve roots within the thecal sac at this level. There is ligamentum flavum hypertrophy present. There is moderate spinal stenosis present. This is stable since the prior examAt L2-3 there is disc desiccation and a disc bulge associated with posterior ligamentous hypertrophy at this level. There is effacement of fluid surrounding the nerve roots within the thecal sac at this level. There is ligamentum flavum hypertrophy present. There is moderate spinal stenosis present. This is stable since the prior examAt L1-2 there is disc desiccation, diffuse disc bulge and some ligamentum flavum hypertrophy associated with a mild degree of spinal stenosis.There is redemonstration of multiple cysts along the kidneys the largest one is in the left kidney inferior pole measuring 10 mm in diameter.
1.Since prior examination patient developed a compression fracture at L5 which has a benign appearance. It appears to be in a late subacute stage2.Since the prior exam spinal stenosis at L4-5 appears to have progressed.3.There is moderate spinal stenosis at L2-3 and L3-4 degenerative changes which is stable since the prior exam.4.There is redemonstration of a mild L1 compression fracture.