Poor mental status, recent fever following LP, epidural hematoma or abscess? 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 epidural space, thecal sac, and spinal cord are preserved with no evidence of spinal canal/neural foraminal narrowing. The conus medullaris terminates at the L2-L3 level.The paraspinal soft tissues are unremarkable.Degenerative changes are specified by the intervertebral level as follows: T11-T12: There is central focal protrusion of disc which abuts thecal sac. No spinal stenosis. No neural foraminal stenosis.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: minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis. L4-L5: broad based central to central to left disc protrusion which abuts thecal sac and minimal to moderate narrowing of the left side lateral recess. L5-S1: broad based disc protrusion central to right which narrows right lateral recess.
1. Relatively low lying conus medullaris without evidence of cord tethering.2. Disc protrusion (herniation) at the level of T11-12, L45 and L5S1 as described above.