41 years Male (DOB:8/29/1975)Reason: RLE radiculopathy History: samePROVIDER/ATTENDING NAME: MICHAEL J LEE MICHAEL J LEE 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. There is a well formed disc at S1-S2 and associated pseudoarticulation along the sacral alla. In general the lumbar spinal canal is small on a congenital basis. The nerve roots within the thecal sac at the L4 vertebral level and at the L3 vertebral level appear to be peripherally distributed. This pattern was present on the previous exam and is unchanged.At L5-S1 there is loss of disc space height, disc desiccation and a broad-based central disc protrusion without significant compromise to spinal canal or neural foramina.At L4-5 there is loss of disc space height, disc desiccation and a broad-based left paramedian disc extrusion. Since the prior exam patient is undergone left-sided facet and laminar surgery at this level there is contrast enhancing soft tissue present along the left hemicord canal and surgical site. There is effacement of the fat at the lateral recesses bilaterally at this level but worse on the left. The right. There is some crowding of nerve roots within the thecal sac present.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.
1.Status post L4-5 left posterior element and hemicanal surgery. Contrast enhancement within the left hemicord canal may be related to postsurgical change. Early scar formation cannot be excluded.2.There is a moderate degree of spinal stenosis present at L4-5 related predominantly to a broad-based left paramedian disc extrusion.3.The spinal canal is small congenital basis.