The report describes mild-moderate intervertebral disc herniation with degenerative changes at L4/L5 and L5/S1 causing the disc at L4/L5 to lie close to the covering of the spinal cord. There are also changes observed suggesting a previous laminotomy surgery.
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1. Disc degeneration at L4-L5 and L5-S1 with discogenic change noted
involving the abutting endplates at L5-S1.
2. Right posterior paramedian disc protrusion at L4-L5, disc material
slightly indenting the right ventral thecal sac but without evidence
of nerve root displacement.
3. Status post left L5-S1 laminotomy. No evidence of residual or
recurrent disc protrusion or extrusion at this level.
4. Mild left L4-L5 and bilateral L5-S1 facet osteoarthropathy.