62 years Male (DOB:2/3/1954)Reason: lumbar stenosis PROVIDER/ATTENDING NAME: BEN-ZION ROITBERG BEN-ZION ROITBERG Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. The conus medullaris on sagittal imaging is grossly intact. There is a mild degree of anterior subluxation of L1 on L2. The patient is status post lower lumbar spine surgery.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is left-sided facet hypertrophy present at this level which was also present on the prior exam and associated with mild encroachment of the nerve roots of the left lateral recess. There is ligamentum flavum hypertrophy present bilaterally at this level. Overall compared to the prior exam there appears to be some mild progression of the facet hypertrophy.At L4-5 there is a diffuse disc bulge present associated loss of disc space height and disc desiccation as well as a moderate degree of bilateral facet and ligamentum flavum hypertrophy. There is disc desiccation present at this level. There is obliteration of CSF within the thecal sac at this level. Disc material extrudes behind the adjacent endplates at this level. Overall the spinal stenosis has not progressed since the previous exam. There is narrowing of the neural foramina bilaterally at this level with the encroachment of the left-sided exiting nerve roots within the neural foramen due to combination of disc disease and facet disease. There is a superimposed left far lateral disc protrusion at this level which is stable compared to the prior exam. The neural foraminal encroachment of the left exiting nerve root is stable since the prior exam. There is redemonstration crowding of the nerve roots within the spinal canal at this level. Overall there is moderate to severe spinal stenosis at this level.At L3-4 there is redemonstration no change of loss of disc space height and a diffuse disc bulge as well as ligamentum flavum hypertrophy. The endplate reactive changes are predominantly bright signal on T1 and suppresses on the inversion recovery T2 images. There is effacement of the fat at the lateral recesses bilaterally at this level which was also present on the prior exam. There is effacement of the CSF surrounding the nerve roots at this level. There is partial effacement of the fat surrounding the exiting nerve roots within the neural foramina at this level. There is a left far lateral disc protrusion at this level which encroaches on the left exiting nerve root which was not evident on the prior exam. There is redemonstration crowding of the nerve roots within the spinal canal at this level. Overall there is moderate to severe spinal stenosis at this level.At L2-3 there is loss of disc space height and diffuse disc bulge as well as mild ligamentum flavum hypertrophy. There is effacement of the fat at the lateral recess bilaterally at this level. There is some narrowing of the neural foramina at this level, however, the exiting nerve roots are surrounded by fat within the neural foramina. Compared to the prior exam loss of disc space height has been unchanged. These endplate reactive changes are predominantly bright signal on T1 and suppresses on the inversion recovery T2 images and unchanged since prior exam. Overall there is a moderate degree of spinal stenosis at this level.At L1-2 there is loss of disc space height, disc desiccation and diffuse disc bulge which has progressed since the prior exam. There is ligamentum flavum hypertrophy present this level as well as a small left-sided ligamentum flavum cyst. Overall there is a mild degree of spinal stenosis at this level.
There are multilevel degenerative changes present in the lumbar spine which have remained stable since 10/26/2015. There is a moderate to severe spinal stenosis at L4-5 and L3-4 and moderate spinal stenosis at L2-3 as detailed above. There is encroachment of exiting nerve roots on the left-sided L4-5 and L3-4 as detailed above. Please note that a contrast enhanced exam may help differentiate postsurgical scar formation from degenerative change.