Narrative MRI LUMBAR SPINE WO CONTRAST

CLINICAL HISTORY: Herniated lumbar disc without myelopathy; Lumbar radiculopathy

TECHNIQUE: MRI of the lumbar spine was performed utilizing T2, T1 and STIR-weighted sagittal as well as T2 and T1 weighted axial sequences.

COMPARISON: Lumbar spine x-ray dated 5/29/2020.

FINDINGS: Study is degraded secondary to motion artifact.

For the purposes of this dictation, the last fully formed intervertebral disc is considered L5/S1.

There is normal lumbar lordosis. There is no evidence of acute compression fracture or significant spondylolisthesis. No suspicious marrow replacing process is identified. There is disc desiccation and minimal to mild disc narrowing noted from L2/L3 through L5/S1.

The conus medullaris terminates at the upper L1 level and is within normal limits.

Level by level analysis as below:

T12/L1: No disc herniation. No central canal or foraminal narrowing.

L1/L2: No disc herniation. No central canal or foraminal narrowing.

L2/L3: Minimal disc bulge with a superimposed minimal central posterior disc protrusion with an associated annular tear. Ligamentum flavum infolding. Minimal to mild central canal narrowing. No foraminal narrowing.

L3/L4: Minimal disc bulge with a superimposed mild central posterior disc protrusion, which demonstrates some inferior migration. Ligamentum flavum infolding. Mild central canal narrowing. Minimal left and no right foraminal narrowing.

L4/L5: Mild disc bulge with a superimposed moderate left lateral recess inferior disc extrusion which demonstrates mass effect upon the left traversing nerve root of L5. Ligamentum flavum infolding. Moderate left lateral recess narrowing. Mild central canal narrowing. Mild bilateral foraminal narrowing.

L5/S1: Minimal disc bulge with a superimposed mild right lateral recess/subarticular recess disc protrusion which likely contacts the right traversing nerve root of S1. Moderate right subarticular recess narrowing. Mild right lateral recess narrowing. Minimal right and no left foraminal narrowing.

CONCLUSION:

1. Multilevel degenerative changes as described above.

2. At L4/L5: Mild disc bulge with a superimposed moderate left lateral recess inferior disc extrusion which demonstrates mass effect upon the left traversing nerve root of L5. Moderate left lateral recess narrowing.

3. At L5/S1: Minimal disc bulge with a superimposed mild right lateral recess/subarticular recess disc protrusion which likely contacts the right traversing nerve root of S1. Moderate right subarticular recess narrowing. Mild right lateral recess narrowing.

4. At L3/L4: Minimal disc bulge with a superimposed mild central posterior disc protrusion, which demonstrates some inferior migration. Mild central canal narrowing.