Impingement syndrome of left shoulder [M75.42] / Pain in thoracic spine [M54.6] / Low back pain [M54.5], Reason for Study: ^Reason: eval for disc herniation History: lbp 2011 with disc herniation; better now but recent strain of the back 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. 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: disc dessication appears to be progressed since prior scan, there is broad based focal disc protrusion central to right which abuts thecal sac. Minimal narrowing of the right side neuroforamen is seen. No spinal stenosis. L5-S1: minimal bulging of disc, unchanged since prior scan, no neuroforaminal narrowing or spinal stenosis.
1. Progressed disc dessication at the level of L45. Slightly changed disc protrusion from central to central to right side with minimal right side neuroforaminal stenosis at the level of L45.2. Unchanged minimal bulging of disc at L5S1 level.