DEPARTMENT OF IMAGING SERVICES
Pt Type: REG CLI Pt Location: IMCANC
Attending:
Referring:
06/24/21 Time: 1351 Primary Care: MD Requisition No:—— Account Number Proceduæs: REPORT NO:
ÄI/MR Spine Lumbar Wo IV
MR Spine Lumbar Wo IV
CLINICAL INDICATION: Backache
TECHNIQUE: Multi sequential MR images of the lumbar spine were obtained multiple planes without intravenous contrast.
COMPARISON: None.
FINDINGS:

For purposes of this dictation, it is assumed thåt there are 5 non-rib-bearing, lumbar-type vertebrae, and the most caudal fully segmented lumbar vertebra is labeled L5.
No acute fracture or subluxation.
There is minimal levoscoliotic curvature centered at 1-44-5 with a rotatory component.
Vertebral bodies are normal in height.
Mild marrow signal changes noted at L5-S1 and to a lesser extent at L2-L3..
There is multilevel loss of disc height and desiccation, most pronounced at L5-S1.
The conus medullaris terminates at a normal level. The nerve roots of the cauda equina appear normal. No epidural fluid collections.
The included paraspinal soft tissues are normal.
The included retroperitoneal structures are normal.
Evaluation of the individual levels demonstrates:
T12-L1: No significant disc abnormality. No significant spinal canal or neural foraminal narrowing.
L1-2: No significant disc abnormality. No significant spinal canal or neural foraminai narrowing.
12-3: There is a small disc bulge with bilateral facet arthropathy and ligamentum thickening causing mild spinal canal narrowing and bilateral subarticular effacement. There is also mild left and minimal right neural foraminat narrowing.
L3-4: There is a disc bulge with bilateral facet arthropathy and ligamentum thickening causing mild spinal canal narrowing and bilateral subarticular effacement. There is also mild bilateral neural foraminal narrowing.
L4-5: There is a disc bulge with bilateral facet arthropathy and ligamentum thickening causing moderate spinal canal narrowing with bilateral subarticular effacement and effacement of the thecal sac. There is also mild left and moderate right neural foraminal narrowing.
1.5-SI: There is a disc bulge with mild bilateral facet arthropathy causing moderate right and moderate to severe left neural foraminal narrowing. No significant spinal canal narrowing. An annular fissure is also noted.
IMPRESSION:
Multilevel degenerative changes of the lumbar spine, as described detail above. These findings are most pronounced at L4-L5, where there is moderate spinal canal narrowing, moderate left and mild right neural foraminal narrowing.