56 years Male (DOB:10/21/1959)Reason: hx LBP and right leg pain. Post epidural injection developed left thigh pain. Eval for disc degeneration or abnormality History: LBP, bilateral leg painPROVIDER/ATTENDING NAME: EDWIN RAMOS EDWIN RAMOS 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.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is bilateral facet hypertrophy present at this level which is relatively stable compared to the prior exam. There is a minor disc bulge at this level. There is some T2 signal hyperintensity along the annulus of the disc posteriorly at this level.At L4-5 there is no significant compromise to spinal canal. There is mild loss of disc space height, disc bulge and disc desiccation at this level associated with a right-sided facet and ligamentum flavum hypertrophy. This was also the case on the prior exam. There is narrowing of the right neural foramen at this level with mild encroachment of the right-sided exiting nerve roots as a result of combination of facet hypertrophy and 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.
There are some degenerative changes present in the lower lumbar spine with mild encroachment of the right-sided exiting nerve roots within the neural foramen at L4-5 related to disc bulge and facet hypertrophy. This is stable and compared to a prior exam from 6/26/2015.