Back pain, history of kidney cancer Lack of contrast limits evaluation for small metastatic lesions. Five lumbar type vertebral bodies are presumed to be present. There is a large mass involving the right aspect of the sacrum measuring approximately 4.6 x 5.2 x 4.9 cm and is centered at the right S2 level. The tumor surrounds the right S2 nerve root and to a lesser degree S3 and S1 roots. There is evidence of epidural extension with effacement of the right aspect of the spinal canal. The left aspect of the spinal canal is patent. Elsewhere in the lumbar spine, no large lesions are evident. Scattered foci of T1 hyperintensity such as at the T12 vertebral body are compatible with hemangiomas. Small focus of T1 hypointensity and T2 hyperintensity involving the superior endplate of L2 is nonspecific. Vertebral body heights are within normal limits. There is trace anterolisthesis of L5 on S1. Alignment is otherwise within normal limits. The conus medullaris is normal in position.Multilevel degenerative changes are seen, as described below:L1-L2: There is mild disc bulge, ligamentum flavum thickening, and bilateral facet arthropathy. There is no significant spinal canal stenosis. No significant neural foraminal stenosis.L2-L3: There is mild disc bulge, ligamentum flavum thickening, and bilateral facet arthropathy. There is no significant spinal canal stenosis. No significant neural foraminal stenosis.L3-L4: There is mild disc bulge, ligamentum flavum thickening, and bilateral facet arthropathy. There is no significant spinal canal stenosis. There is minimal bilateral neural foraminal narrowing.L4-L5: There is loss of disc height, disc bulge, ligamentum flavum thickening, and advanced bilateral facet arthropathy. There is resulting moderate spinal canal stenosis. There is mild to moderate bilateral neural foraminal narrowing.L5-S1: Grade 1 anterolisthesis with disc uncovering. There is advanced bilateral facet arthropathy. There is partial effacement of the lateral recesses. No significant central canal stenosis. There is minimal right and mild to moderate left neural foraminal stenosis.
1. Large right sacral mass most compatible with metastatic disease. There is evidence of epidural extension with effacement of the right lateral aspect of the sacral spinal canal. Postcontrast imaging may be helpful to further assess extent of epidural tumor and smaller additional lesions.2. Multilevel degenerative changes in the lumbar spine with moderate spinal canal stenosis at the L4-L5 level. Additional details as above.Dr. Ali discussed findings with Dr. Renz at 940 hrs on 2/23/2016 