74 years Female (DOB:4/15/1942)Reason: lumbar radiculopathy History: lumbar radiculopathyPROVIDER/ATTENDING NAME: MICHAEL J LEE MICHAEL J LEE The patient status post lumbar spine surgery with posterior and anterior fusion. There are pedicle screws present at L4 and L5 associated with interconnecting rods. There is a laminectomy defect present at L4-5. There is osseous fusion across the L4-5 disc space.At L5-S1 there is no significant compromise to spinal canal. There is some loss of disc space height and disc protrusions into the neural foramina with encroachment of the exiting nerve roots within the neural foramina. There is facet hypertrophy present at this level. There is fluid present within the facet joints.At L4-5 there is no significant compromise to spinal canal or neural foramina appreciated. The patient status post anterior fusion at this level and surgery. Visualization at this level is somewhat obscured by metal artifact. This mild anterior subluxation of L4 on L5.At L3-4 there is a diffuse disc bulge present associated with disc desiccation and bilateral facet and ligamentum flavum hypertrophy. There is narrowing of the spinal canal and effacement of the fat at the lateral recess bilaterally at this level. There is narrowing of the neural foramina bilaterally at this level with encroachment of the exiting nerve roots on the left side. Overall there is a moderate degree of spinal stenosis at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is a diffuse disc bulge at this level associated with endplate reactive changes and disc desiccation and loss of disc space height. There is encroachment of the nerve roots at the left lateral recess at this level. Although the neural foraminal are narrowed, within the neural foramina the exiting nerve roots are surrounded by fat.At L1-2 there is no significant compromise to spinal canal or neural foramina.There is a fatty filum terminale present.There are some degenerative changes present in the visualized lower thoracic spine with disc bulges, loss of disc space height and disc desiccation.
1.The patient status post lumbar spine surgery with posterior fusion and laminectomies at L4-5 and anterior fusion at L4-5.2.There is a moderate degree of spinal stenosis present at L3-4 related to disc disease and facet disease. This associated with encroachment of left-sided exiting nerve roots within the left neural foramen.3.There is encroachment of the nerve roots at the left lateral recess at L2-3 related to degenerative changes and a disc bulge.