Diagnosis: Radiculopathy, lumbar regionClinical question: lumbar radiculopathySigns and Symptoms: leg painComments: Pt will have PO valium to take before MRI | Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild loss of disc space height, mild disc desiccation and a minor disc bulge at this level associated with a mild to moderate degree of facet hypertrophy.At L4-5 there is loss of disc space height, disc desiccation and diffuse disc bulge associated with some facet hypertrophy. There is a 3 mm posterior subluxation of L4 on L5. There is effacement of the fat at the lateral recess bilaterally at this level. The exiting nerve roots within the neural foramina are surrounded by fat on the left side, however it is partially effaced on the right side. Overall there is a mild to moderate degree of spinal stenosis present at this level. Lung the adjacent endplates there is some mild T2 signal hyperintensity along the right half of the disc space.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation at this level as well as a mild disc bulge and a moderate degree of facet and ligamentum flavum hypertrophy. There is crowding of the nerve roots within the thecal sac at this level. Overall there is a moderate degree of spinal stenosis at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina. There is disc desiccation at this level associated with a mild disc bulge and mild to moderate ligamentum flavum and to lesser degree facet hypertrophy. There is a mild crowding of nerve roots within the thecal sac at this level. Overall there is mild spinal stenosis at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.
There are multilevel degenerative changes present in the lumbar spine with moderate spinal stenosis at L3-4 and mild to moderate spinal stenosis at L4-5 where there is some mild subluxation and a small amount of subacute endplate reactive change. There is also some mild to moderate encroachment of right-sided exiting nerve roots at L4-5.