Malignant melanoma of skin, unspecified [C43.9], Reason for Study: ^Reason: Evaluate for metastatic disease History: Stage IV melanoma with increased frequency of pain For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. Focal enhancement at anterior superior aspect of L2 vertebral body with STIR high signal intensity indicate focal degenerative changes.There is no evidence of vertebral body compression fracture. There is no evidence of focal mass or enhancing mass.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. The paraspinal soft tissues are unremarkable.There is no evidence of abnormal enhancement, cord compression or mass. Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: Minimal bulging of disc. No neuroforaminal narrowing or spinal stenosis. L2-L3: Diffuse bulging of disc. No neuroforaminal narrowing or spinal stenosis. L3-L4: Disc desiccation. Diffuse bulging of disc which abuts thecal sac. Associated with bilateral ligamentum flavum thickening, there is minimal to mild spinal canal stenosis. L4-L5: Disc desiccation. Diffuse bulging of disc with broad based disc bulging through the left side neuroforamen which results mild to moderate left side neuroforaminal stenosis. L5-S1: Disc desiccation. No neuroforaminal narrowing or spinal stenosis.
1. No evidence to compression fracture. No evidence of spinal cord compression.2. Focal abnormal enhancement of anterosuperior aspect of the L2 vertebral body indicating degenerative changes. Otherwise, no abnormal enhancing lesion.3. No evidence of spinal cord compression.4. Minimal to mild spinal canal stenosis at the level of L34.5. Mild to moderate L45 left side neuroforaminal stenosis. 