Headache [R51], Reason for Study: ^Reason: any evidence of CSF leak post contrast History: headaches post-exerctional after bearing down 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 epidural space, thecal sac, and spinal cord are preserved with no evidence of spinal canal/neural foraminal narrowing. The conus medullaris terminates at the L1-2 level. The intervertebral discs demonstrate normal T2 intensity and height with no evidence of disc herniation. The paraspinal soft tissues are unremarkable.Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: no neuroforaminal narrowing or spinal stenosis. L4-L5: no neuroforaminal narrowing or spinal stenosis. L5-S1: minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis.
Normal L-spine MRI scan except minimal bulging of disc at the level of L5-S1.Comment: If clinically indicated, nuclear medicine cisternogram can be considered for further imaging evaluation of CSF leakage.