Radiculopathy, lumbar region [M54.16], For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is normal lumbar lordosis. 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. Degenerative changes are specified by the intervertebral level as follows: T12-L1: Disc desiccation. No neuroforaminal narrowing or spinal stenosis. L1-L2: Disc desiccation. Bilateral ligamentum flavum thickening. No neuroforaminal narrowing or spinal stenosis. L2-L3: Disc desiccation with bilateral ligamentum flavum thickening. No neuroforaminal narrowing or spinal stenosis. L3-L4: Disc desiccation. Diffuse bulging of disc with bilateral ligamentum flavum thickening results mild to moderate spinal canal stenosis at this level. L4-L5: Disc desiccation. There is grade 1 anterolisthesis of L4 on L5. There is a pseudo bulging of disc of L4-5 with bilateral ligamentum flavum thickening and sclerotic changes of bilateral facet joints results mild spinal canal stenosis. L5-S1: Disc desiccation. There is grade 1 anterolisthesis of L5 on S1. Sclerotic changes of bilateral facet joints with minimal thickening of ligamentum flavum thickening are seen. No definitive evidence of spinal stenosis.
1. Degenerative spondylosis of lumbar spine.2. Grade 1 spondylolisthesis of L4 on L5 and L5 on S1.3. Mild to moderate spinal canal stenosis at the level of L3-4.