Closed fracture of unspecified bone Backache, malaise and fatigueClinical question: severe pain from buttock to R leg. Hx of osteoporosis, lumbar spine compression fracture on x-raySigns and Symptoms: pain and weakness. Hx of myositis and osteoporosis Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment. The conus medullaris on sagittal imaging is grossly intact. There is disc desiccation present. The sacroiliac joints are narrow and partially fused.There is a mild superior endplate compression present at L5. There is a CT of the abdomen from 2011 which suggests that this is been present since that time. There is T2 signal hyperintensity present along the superior aspect of the L5 vertebral body.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild facet hypertrophy present at this level and a minor disc bulge. At L4-5 there is bilateral facet hypertrophy associated with a disc bulge and effacement of fat at the lateral recesses. The fat surrounding the exiting nerve roots within the neural foramina is not effaced. Overall there is a mild degree of spinal stenosis at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is some disc desiccation and a mild left far lateral disc protrusion at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation with a mild disc bulge at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.Cysts are present in the visualized portions of the kidneys which have also been identified on CT of the abdomen from 6/6/2011.There is significant fatty replacement present throughout the paravertebral musculature. This has been present on the prior abdomen CT from 2011
1.There are degenerative changes present in the lumbar spine with mild spinal stenosis at L4-5.2.There is a mild superior endplate compression present at L5 which has been present since 2011 at least, however, some associated signal changes suggest that there may be some current inflammatory change probably related to some exacerbation of the superior end plate compression.3.There is fatty replacement of much of the visualized paravertebral musculature. There is isolated fatty replacement of the some of the gluteal musculature. Please correlate to patient's clinical history. This is long standing. Differential considerations may include polymyositis, though it is non-specific.