Low back pain [M54.5], Reason for Study: ^Reason: Is there a localized lesion to explain the recalcitrant back pain such as stress fracture or annulus tear? History: mid-lumbar back pain in a diver 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 T12 level. 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: no neuroforaminal narrowing or spinal stenosis. L4-L5: Minimal bulging of disc. No neuroforaminal narrowing or spinal stenosis. L5-S1: no neuroforaminal narrowing or spinal stenosis.
Minimal bulging of disc at the level of L4-5 otherwise unremarkable.