Spinal stenosis, lumbar region [M48.06], Reason for Study: ^Reason: ?lumbar spinal stenosis History: radicular pain in a saddle distribution, decreased patellar reflexes For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. 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. There is no evidence of abnormal enhancement, cord compression or mass. 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 disc dessication, no neuroforaminal narrowing or spinal stenosis. L4-L5: mild disc dessication, diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L5-S1: mild disc dessication, there is disc extrusion toward left side lateral recess and compressed nerve root. No evidence of spinal stenosis.
1. Disc extrusion at the level of L5S1 toward left side lateral recess as described above.2. Multilevel disc degenerative changes as described above.