Back pain, recurrent, Lumbago [724.2] For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. Normal lumbar lordosis appear to be slightly decreased. 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. The paraspinal soft tissues are unremarkable.Degenerative changes are specified by the intervertebral level as follows: L1-L2: no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: Diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L4-L5: Diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L5-S1: There is evidence of right side hemi-laminectomy. Decreased disc height with low signal intensity of intervertebral disc on both T1 and T2-weighted images indicating disc desiccation and degeneration. There is osteophyte from the right side facet joint toward neural foramen narrowing the right side neural foraminal recess. In addition, there appears to be soft tissue lesion connected to the intervertebral disc showing central to right focal bulging of disc which abuts thecal sac. Since this scan was not performed with contrast enhancement, differentiation between disc herniation from postoperative scar cannot be performed.
1. Post hemilaminectomy status of the right L5.2. Central to right broad based disc herniation which abuts thecal sac, differential diagnosis of this lesion could be postoperative scar formation, if clinically indicated, Gad enhanced MRI can be considered. 3. Right side facet joint osteophyte narrows right side lateral recess stenosis at the level of L5S1.4. Disc degeneration with Modic 2 endplate changes of L5S1.