Other specified postprocedural states [Z98.89], Reason for Study: ^Reason: s/p l4-5 microdisc History: same For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. The spine alignment is anatomic. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The signal of the visualized cord is normal. The conus medullaris terminates at the T12-L1 level. Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: no neuroforaminal narrowing or spinal stenosis. L4-L5: There is evidence of left side laminectomy. There is non enhancing T1 and T2 low signal intensity lesion seems to be attached to remained L45 disc seen on the left side lateral recess. Considering this exam was obtained within 2-3months after microdiscectomy, the diagnostic possibility of this lesion include 1) residual or recurrent disc material or 2) postoperative blood products. The disc height has decreased, unchanged. L5-S1: no neuroforaminal narrowing or spinal stenosis.
1. Post laminectomy and microdiscectomy status of L45 extruded disc.2. Non enhancing lesion located on the left side lateral recess of L45 disc space, diagnostic possibilities include 1) residual or recurrent disc material and 2) postoperative blood products.