Scoliosis surgery in 1966/1967
The prevertebral and paraspinal muscles appear grossly unremarkable.
Findings level by level:
T12-L1: No significant spinal canal stenosis or neural foraminal
L1-2: There is a left subarticular to foraminal disc protrusion which
causes mild-to-moderate left neural foraminal narrowing with possible
impingement of the left exiting L1 nerve root. There is no
significant spinal canal stenosis or right neural foraminal narrowing.
L2-3: There is a shallow disc bulge and bilateral facet hypertrophy,
together resulting in mild-to-moderate right neural foraminal
narrowing but no significant spinal canal stenosis or left neural
L3-4: There is a disc bulge with superimposed left as well as right
foraminal to lateral disc protrusions, and bilateral facet
hypertrophy with prominent ligamentum flavum infolding. Altogether,
these produce moderate spinal canal stenosis and moderate bilateral
neural foraminal narrowing. There is likely impingement of bilateral
exiting L3 nerve roots.
L4-5: Postsurgical changes of probable bilateral laminectomy, though
correlation with surgical history is recommended. There is a
broad-based posterior disc protrusion as well as severe bilateral
facet hypertrophy, and left ligamentum flavum infolding, all together
resulting in mild-to-moderate spinal canal stenosis with mild
bilateral neural foraminal narrowing.
L5-S1: There is no significant spinal canal stenosis. Possible
postsurgical changes, for which clinical correlation is recommended.
No evidence of high-grade neural foraminal narrowing on the right or
Note made of a fluid distended bladder.
1. Vertebral body numbering as detailed above. Accessory ribs noted
at L1. Probable partial sacralization of L5.
2. Grade 3 anterolisthesis of S1 on S2 without associated marrow
edema to suggest acute or subacute etiology. Clinical correlation
3. Presumed postsurgical changes at L4-5 and possibly also at L5-S1;
correlation with surgical history recommended.
4. Multifactorial degenerative changes produce moderate and
mild-to-moderate spinal canal stenosis at L3-4 and L4-5,
respectively, as well as varying degrees of neural foraminal
narrowing throughout the lumbar spine, worst at bilateral L3-4 where
there is also impingement of the exiting L3 nerve roots.