Here goes my report. What is your opinion based on report of MRI?
EXAM: MRI Lumbar Spine W/WO (72158)
History: Saglttal, coronal, and transexial images of the lumbar spine are provided utilizing various techniques to include sequences post intravenous ministration of 15cc Dolarem.
Comparision: 7/28/2016
Finding:
He patient is satus interval left L4-5 laminectomy and discectomy as compared to the previous study. Importantly, a large left epidural soft tissue collection in the spinal canal prolapsing/migrating inferiorly compatible with a large extruded disc herniation and/or sequestered free disk fragment is noted posterior to the mid to upper aspect of L4 with marked spinal canal stenosis. His also causes stenosis of the left lateral recess. He thecal sac is extrinsically compressed and displaced to the right. he exiting neural foraman are relatively spared. Asymmetric l4-5 facet arthropathy on the left is greater than the right is noted with mild left face joint effusion. Mild disc desiccation in the L4-5 disc is seen.
He remaining discs are more normally hydrated. No interval significant degeneration spondylosis is appreciated. No disc herniation or spinal canal narrowing is seen elsewhere. No spinal or paraspinal mass lesion is evident. Lumbar alignment is normal in the supine position. He conus medullaris terminates normally behind L1. No interval significant facet disease is seen elsewhere.
Impression:
Status post interval left L4-5 laminectomy/discectomy.
Importantly, large L4-5 inferior prolapsed/migrated extruded disc herniation plus/minus sequestered/free disk fragment marked spinal canal stenosis left lateral recess stenosis as well, the remainder of the spine exam is unmarkable
