71 years Male (DOB:5/3/1945)Reason: preop eval for decompression. Evaluate stenosis History: back pain leg painPROVIDER/ATTENDING NAME: EDWIN RAMOS EDWIN RAMOS Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is a right paramedian disc extrusion present which abuts the nerve root at the right lateral recess which is new since the 12/24/2013 exam.. Some disc material extends behind the inferior endplate of L5. There is loss of disc space height, disc desiccation and a disc bulge at this level. There is bilateral facet and ligamentum flavum hypertrophy at this level. The facet hypertrophy is worse on the left versus the right side. There are some encroachment of the nerve root at the left lateral recess at this level. There is narrowing of the neural foramina bilaterally at this level with some mild encroachment of the right-sided exiting nerve root foramen. There is some epidural lipomatosis at this level with effacement of the thecal sac.At L4-5 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with bilateral facet and ligamentum flavum hypertrophy. There is crowding of the nerve roots within the thecal sac at this level. There is effacement of fat at the lateral recesses and surrounding the thecal sac. Overall there is a moderate degree of spinal stenosis present which is stable compared to the prior exam.. Behind the L4 vertebral body there is epidural lipomatosis associated with crowding of nerve roots. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat. There is a Schmorl's this level.At L3-4 there is loss of disc space height, disc desiccation and a disc bulge associated with some ligamentum flavum hypertrophy and partial effacement of fat at the lateral recesses bilaterally which was also present on the prior exam and has not changed significantly. There are Schmorl's nodes at this level. Overall there is mild to moderate spinal stenosis at this level. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L2-3 there is loss of disc space height, disc desiccation and a disc bulge associated with Schmorl's nodes. A disc bulge has mildly progressed since the prior exam There is some ligamentum flavum hypertrophy at this level and some crowding of the nerve roots within the thecal sac. There is thickening of the right ligamentum flavum associated with it T2 signal hyperintense focus which was not present on the prior exam. Overall there is mild to moderate spinal stenosis at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation at this level.It appears that a bowel loop probably duodenum abuts the right renal pelvis.
1.There is epidural lipomatosis present in the lower lumbar spine from L4 down to S1. This results in spinal stenosis. It was also present on the prior MRI exam2.There is a moderate degree of spinal stenosis present at L4-5 related to degenerative changes. This was also present on the prior exam and has not changed substantially.3.There is a new right paramedian disc extrusion present which abuts the nerve root at the right lateral recess at L5-S1.4.There is encroachment of the nerve roots of the left lateral recess at L5-S1 due to facet hypertrophy and disc disease.5.There is mild to moderate spinal stenosis present at L3-4 and L2-3. At the L2-3 level there is some mild progression related to a ligamentum flavum cyst and a disc bulge.