Radiculopathy, lumbar region [M54.16], Reason for Study: ^Reason: assess for lumbar spinal stenosis/radiculopathy History: gait impairment/ radicular pain For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is grade 1 anterolisthesis of L4 on L5 associated with bilateral ligamentum flavum thickening resulting severe spinal stenosis at this level.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 T12-L1 level. Degenerative changes are specified by the intervertebral level as follows: T12-L1: disc dessication, otherwise unremarkable. L1-L2: disc dessication, minimal bulging of disc and bilateral ligamentum flavum thickening results minimal spinal canal stenosis.L2-L3: disc dessication, minimal bulging of disc and bilateral ligamentum flavum thickening.L3-L4:disc dessication, minimal bulging of disc and bilateral ligamentum flavum thickening results minimal spinal canal stenosis.L4-L5: Grade 1 anterolisthesis of L4 on L5 associated with bilateral ligamentum flavum thickening results severe spinal canal stenosis. L5-S1: Diffuse bulging of disc with eccentric disc protrusion toward right side neural foramen results moderate right neuroforaminal stenosis.
1. Grade 1 anterolisthesis of L4 on L5 with severe spinal stenosis at the level of L45.2. Multilevel various degree degenerative disease of lumbar spine as described above.