Hereditary ataxia, unspecified [G11.9] / Other symptoms and signs involving the musculoskeletal system [R29.898], Reason for Study: ^Reason: left side root entrapment History: ataxia and leg weakness, sciatica For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There are disc herniations one at the level of L34, toward left neural foramen which abuts left L3 nerve root, and another one is L45, toward right side neural foramen which abuts right L4 nerve root.There is lenticular shaped low signal intensity lesion at the level of L23 which appears to be connected with L34 disc thus indicate extruded disc material with cranial migration but could represent sequestrated disc.There is Modic type 2 degenerative changes of L45. 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 T12-L1 level.
1. Left neural foraminal disc herniation (extrusion) at the level of L34 with cranial migration of disc material.2. Right neural foraminal disc herniation (protrusion) at the level of L45 with mild neuroforaminal stenosis.3. Modic type 2 degenerative changes of L45 disc space.