Radiculopathy, site unspecified [M54.10], Reason for Study: ^Reason: eval for nerve compression History: worsening bilateral LE pain plus low back pain in setting of degen lumbar spine xr... no specific one dermatomal/myotomal weakness. For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. The bone marrow signal intensity of lumbar spine shows low signal intensity on T1 with remained fatty marrow signals on the inferior endplate of L2 and L4 as well as superior endplate of L5. This finding indicate possible bone marrow replacement such as anemia, myelodysplasia, metastasis, or diffuse sclerotic changes. Clinical correlation is indicated.There is no evidence of bone marrow edema indicating acute compression fracture.The signal of the visualized cord is normal. The conus medullaris terminates at the L1 level.Degenerative changes are specified by the intervertebral level as follows: T12-L1: disc dessication, no neuroforaminal narrowing or spinal stenosis. L1-L2: disc dessication,diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L2-L3: diffuse bulging of disc with right severe lateral recess as well as neuroforaminal stenosis. L3-L4: disc dessication, diffuse bulging of disc, minimal to moderate left neuroforaminal stenosis. L4-L5: disc dessication, diffuse bulging of disc central focal protrusion which abuts thecal sac, there is moderate degree left side neuroforaminal stenosis. L5-S1: disc dessication, diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis.
1. Diffuse bone marrow signal abnormality seen at lumbar vertebrae, sacrum, coccyx and bilateral ilium. Clinical correlation regarding possible bone marrow replacement lesions is recommended.2. Degenerative spondylosis with mild to moderate spinal canal stenosis at the level of L23, L34 and L45.3. Severe neuroforaminal stenosis at the right L23.4. Mild to moderate neuroforaminal stenosis at the left side L34 and L45 neural foramen. 