Pain In Right Leg [M79.604] / Dorsalgia, unspecified [M54.9], Reason for Study: ^Reason: R/O compressed or irritated nerve root History: Right lateral leg pain numbness, originally starting in the lower back now mostly involving the leg 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 L1 level. There is about 6mm sized renal cyst on the right kidney.Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: disc dessication, Schmorl's node on the inferior endplate of the L1 vertebral body. minimal to mild facet joint hypertrophy (left worse than right). no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: disc dessication, bilateral ligamentum flavum thickening, no neuroforaminal narrowing. L4-L5: grade 1 anterolisthesis of L4 on L5 with pseudobulging of disc with disc dessication results minimal to mild spinal canal stenosis. There is 4.4mm x 9.7mm sized fluid filled lesion on the lateral aspect of the right L45 facet joint which may indicate degenerative change related synovial cyst.L5-S1: disc dessication with exuberant osteophytes on bilateral facet joints indicating degenerative facets bilaterally.
1. Grade 1 anterolisthesis of L4 on L5 with minimal to mild spinal canal stenosis at the level.2. Multilevel various degree degenerative changes of intervertebral discs and facet joints as described above including L45 right side synovial cyst.