Diagnosis: Thoracic or lumbosacral neuritis or radiculitis, unspecified Other postprocedural status(V45.89)Clinical question: recurrent disc herniation?Signs and Symptoms: RLE radic s/p microdiscx 3 mos 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 some T2 hyperintense signal present along the superior and anterior aspect of the T12 vertebral body which on the accompanying plain films appears represent discogenic sclerosis.At L5-S1 there is a right lateral recess disc extrusion which appears similar in size compared to the prior exam and extends towards the right lateral recess and encroaches on the nerve root at the right lateral recess. There is loss of disc space height, disc desiccation and some mild endplate reactive changes present at this level. The exiting nerve roots within the neural foramina are surrounded by fat. The patient is status post L5-S1 surgery along the right posterior elements. There is contrast enhancement at the right laminotomy site at L5-S1. There is contrast enhancement present adjacent to the disc protrusion at the L5-S1 right lateral recess which involves the right nerve root at the right lateral recess at this level.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is mild facet and ligamentum flavum hypertrophy present at this level. There is a mild disc desiccation at this level associated with a minor disc bulge.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.Since the prior examination the patient is undergone surgery at the L5-S1 level. There is a large disc extrusion present at the right lateral recess at the L5-S1 level which affects the nerve root at the right lateral recess (most likely right S1 nerve root) associated contrast enhancement at this level could represent a small amount of scar formation adjacent to the nerve root. The disc extrusion appears similar in size when compared to the prior exam