42 years Female (DOB:7/31/1973)Reason: nerve impingement? History: back pain and progressive weakness/numbnessPROVIDER/ATTENDING NAME: TERESITA M HOGAN TIPU S PURI 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. He T1 signal hyperintense 10 mm lesion is present within the L3 vertebral body which was also present on the prior exam and most likely represents a vertebral body hemangioma.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is loss of disc space height, disc desiccation and a disc bulge at this level. There is partial effacement of the fat at the lateral recess bilaterally at this level.At L4-5 there is loss of disc space height, disc desiccation, diffuse disc bulge as well as facet and ligamentum flavum hypertrophy. There is a narrowing of the thecal sac with effacement of spinal fluid surrounding the nerve roots within the thecal sac and effacement of the fat at the lateral recesses bilaterally. There is mild narrowing of the neural foramina at this level. Overall there is a moderate to severe degree of spinal stenosis at this level. This has not changed significantly since the prior exam from 4/9/2014.At L3-4 there is loss of disc space height, disc desiccation and a broad-based central disc protrusion with disc material extending behind the adjacent endplates. There is associated facet and ligamentum flavum hypertrophy at this level. There is effacement of the fat at the lateral recess bilaterally. There is crowding of the nerve roots with partial effacement of spinal fluid surrounding the nerve roots. Overall there is a moderate degree of spinal stenosis at this level. This has not changed significantly since the prior exam from 4/9/2014.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.There is a partially visualized large expanded fluid collection in the abdomen. There is a prior CT of the abdomen from 5/7/2013 which seems to indicate this represents a partially cystic mass and possibly ovarian in origin. It is only partly imaged on this exam.
1.There are multilevel degenerative changes present lumbar spine with moderate to severe spinal stenosis at L4-5 and moderate spinal stenosis at L3-4. This was also present on the prior exam from 2014.2.There is a large cystic type lesion the abdomen which is not evaluated on this exam. There is a CT of the abdomen from 2013 which at that time suggested that an ultrasound would help resolve it. Please correlate with patient's clinical history.