Low back pain [M54.5], Reason for Study: ^Reason: evaluating lumbar discs History: chronic lumbar back pain, pt reported h/o chronic lumbar disc dz, pain worsening, notes change in urinary stream 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 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.Degenerative changes are specified by the intervertebral level as follows: T12-L1: minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis. L1-L2: minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis. L2-L3: minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis. L3-L4: minimal bulging of disc, no neuroforaminal narrowing or spinal stenosis. L4-L5: broad based disc bulging with central disc protrusion which abuts thecal sac, associated with bilateral ligamentum flavum thickening, there is moderate degree spinal stenosis. L5-S1: there is broad based central to left disc protrusion which narrows left lateral recess.
1. Central disc protrusion with moderate spinal canal stenosis at the level of L45.2. Central to left broad based disc protrusion results left lateral recess narrowing at the level of L5S1.