Clinical question: 39-year-old male status post MVA with pain in the lower lumbar spine with numbness. Evaluate. Signs and symptoms: Left leg numbness. Nonenhanced lumbar MRI:There is normal anatomical alignment of vertebral column however with straightening of lumbar lordosis which could be positional.T11-T12 is unremarkable.T12-L1 is unremarkable.L1-L2 is unremarkable.L2-L3 demonstrate mild hypertrophic changes of the facets and ligamentum flavum and unremarkable otherwise.L3-L4 demonstrate mild disc disease and mild loss of disc height, mild bilateral ligamentum flavum hypertrophy, mild bilateral facet disease and bilateral facet effusion. No spinal stenosis or neural foraminal compromise.L4-L5 demonstrate moderate disc disease and loss of disc height, mild bilateral facet and ligamentum level and hypertrophy and mild bilateral facet effusion. There is a shallow broad-based disc/osteophyte complex on the right which in combination with hypertrophic changes of posterior elements results in moderate right neural foraminal compromise and no central spinal stenosis.L5-S1 demonstrate mild disc disease, mild bilateral facet and ligamentum flavum degenerative changes creating bilateral facet effusion. There is a central and leftward broad-based disc protrusion with subtle mass effect on the thecal sac with resultant left lateral recess compromise. No spinal stenosis however mild neural foraminal compromise.
1.At L4-5 there is evidence of degenerative changes of the spine and a right-sided disc-osteophyte complex with resultant mild right neural foraminal compromise.2.At L5-S1 there is mild degenerative changes and including a central and left lateral disc protrusion resulting in left lateral recess compromise as detailed.3.Mild degenerative changes at other levels as detailed.4.Unremarkable perispinal soft tissues.