Radiculopathy, lumbosacral region [M54.17], Reason for Study: ^Reason: r/o disc herniation or mass of the lumbar sacral spine. History: low back pain, radiculopathy For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. 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 conus medullaris terminates at the L1-L2 level. The paraspinal soft tissues are unremarkable.Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: mild diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L4-L5: broad based disc protrusion toward left side neural foramen. no spinal stenosis. L5-S1: disc dessication, central focal protrusion of disc which abuts thecal sac. no neuroforaminal narrowing or spinal stenosis.
1. Disc protrusion toward left side neural foramen at the level of L452. Central disc protrusion at the level of L5S1. 