Falls, weakness. Evaluate for cord compression. Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. There is exaggerated lumbar lordosis as seen previously. There is grade 1 anterolisthesis of L4 and L5 which is grossly similar to prior. There is also minimal retrolisthesis of L2 on L3 which appears worse since 3/21/2006. Bone marrow signal is benign. The conus medullaris is normal in position.There are postsurgical changes of laminectomy from L2 to L5 as seen. Multilevel degenerative changes as detailed below:L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: There is a disc bulge and bilateral facet arthropathy. Disc bulge is larger than on prior study from 3/21/2006. There is evidence of prior laminectomy. No significant spinal canal stenosis. There is moderate bilateral neural foraminal stenosis. L3-L4: There is a disc bulge and bilateral facet arthropathy, as well as ligamentum flavum thickening. There is a prior laminectomy. There is mild degree of spinal canal stenosis. There is also effacement of the left lateral recess. There is moderate neural foraminal stenosis, left worse than right. L4-L5: Mild disc bulge and bilateral facet arthropathy. There is also ligamentum flavum thickening and evidence of prior laminectomy. There is mild degree of spinal canal stenosis. There is also mild to moderate bilateral neural foraminal stenosis.L5-S1: There is disc bulge which is again seen and vacuum phenomena involving the disc space which appears new since prior. There is effacement of the left lateral recess which is worse since prior. No significant central canal stenosis. Prior laminectomy. There is moderate to severe left and mild to moderate right neural foraminal stenosis. These findings are slightly worse in the interval.There is a lobulated mass with heterogeneous T2 hyperintensity involving the superior pole of the left kidney measuring approximately 4.2 cm in diameter and is partially imaged. Small cysts are additionally present in the bilateral kidneys.
1. Suspicious-appearing, partially imaged mass involving the upper pole of the left kidney. Recommend CT abdomen for further assessment. Dr. Ali discussed findings with Dr. Deshmukh at 1610 hours on 9/22/2016.2. Degenerative changes throughout the lumbar spine which have mildly progressed in the interval. Again seen is evidence of prior laminectomies from L2 to L5. There is mild spinal canal stenosis at L3-L4 and L4-L5. There is no high-grade spinal canal stenosis at any level. Additional details as above.