Dorsalgia, unspecified [M54.9], Reason for Study: ^Reason: r/o mets History: back pain and radiculopathy For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is normal lumbar lordosis. The spine alignment is anatomic. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The signal of the visualized cord is normal. The conus medullaris terminates at the T12-L1 level.The paraspinal soft tissues are unremarkable.There is no evidence of abnormal enhancement, cord compression or mass. Degenerative changes are specified by the intervertebral level as follows: T12-L1: disc dessication, no neuroforaminal narrowing or spinal stenosis. L1-L2: disc dessication, minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis. L2-L3: disc dessication, minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis. L3-L4: disc dessication, there is focal obliteration of epidural fat at the left lateral recess indicating possible disc extrusion (series 6, image 23/39). L4-L5: disc dessication, diffuse bulging of disc with broad based disc protrusion toward central to right direction which abuts thecal sac. No spinal stenosis. Modic type 2 changes of L45 endplates.L5-S1: disc dessication, diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. Modic type 2 changes of L45 endplates.
1. Degenerative changes of lumbar spine.2. Focal disc extrusion at the level of L34 toward left lateral recess.3. Broad based disc protrusion at the level of L45.