Abnormal findings on diagnostic imaging of other parts of musculoskeletal system [R93.7], Reason for Study: ^Reason: Abnormal plain film at the VA with sclerotic appearance of L5 vertebral body concerning for osteoblastic met, though hypertrophic DJD cons For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is normal lumbar lordosis. There is minimal anterolisthesis of L4 on L5.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 right renal cyst was seen.Degenerative changes are specified by the intervertebral level as follows: T12-L1: disc dessication, no neuroforaminal narrowing or spinal stenosis. L1-L2: disc dessication, there is diffuse minimal bulging of disc especially toward the left side neuroforamen without significant neuroforaminal narrowing, no evidence of spinal stenosis. L2-L3: disc dessication, no neuroforaminal narrowing or spinal stenosis. L3-L4: disc dessication, diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L4-L5: disc dessication, grade 1 anterolisthesis of L4 on L5, minimal to mild spinal canal stenosis due to bilateral ligamentum flavum thickening, diffuse bulging of disc toward neural foramen bilaterally (left worse than right) results minimal neuroforaminal narrowing. L5-S1: disc dessication, focal broad based disc protrusion central to right lateral which abuts thecal sac. No neuroforaminal narrowing or spinal stenosis.
1. Degenerative lumbar disc disease.2. Multi-level disc bulges as described above, especially at the level of L45 there is grade anterolisthesis of L4 on L5 with minimal to mild spinal canal stenosis.