Pain, unspecified [R52], Reason for Study: ^Reason: evaluate for disc herniation, nerve root compression History: L leg paresthesias, numbness, severe pain For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. Motion artifacts degraded exam quality especially axial scan. If clinically necessary, the exam can be repeated.There is slight loss of 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 T12-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: There is foraminal focal disc protrusion on the left side narrowing neuroforamen. Disc dessication is seen. No spinal stenosis. L3-L4: There is broad based disc protrusion toward left side neuroforamen results neuroforaminal stenosis. No spinal stenosis. Disc dessication is seen.L4-L5: Diffuse bulging of disc abuts thecal sac. no neuroforaminal narrowing or spinal stenosis. L5-S1: Diffuse bulging of disc. no neuroforaminal narrowing or spinal stenosis.
1. Multilevel disc protrusions including L23 and L34 toward left side neuroforamen as described above.2. No evidence of spinal cord signal abnormality.