(MRI 11/09/2021 7PM @ ETMG)

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ORDERING PHYSICIAN: NASH, BARRINGTON
REASON FOR EXAM: M54.9 Dorsalgia, unspecified

Examination: MRI lumbar spine without contrast.

Technique: Routine multiplanar multisequence MRI of the lumbar spine was performed (including axial and sagittal T1 and T2 sequences, sagittal STIR, in and out of phase sagittal sequences) without intravenous contrast.

Comparison: June 7, 2021

Findings: This study assumes the last fully formed intervertebral disc as L5-S1.

There is normal alignment of the lumbar spine. Congenital narrowing of the spinal canal. Vertebral body heights and bone marrow signal are preserved. There is no fracture or subluxation.

The conus medullaris terminates at the L2 level, and demonstrates normal signal. There is no abnormal thickening of the cauda equina nerve roots.There is no extramedullary or intradural abnormality.

At L1-L2, Central protrusion indents the ventral thecal sac. No spinal canal narrowing. No neuroforaminal narrowing.

At L2-L3, disc bulge along with ligamentum flavum buckling contributes to mild canal narrowing. There is moderate right and mild left neuroforaminal narrowing.

At L3-L4, disc bulge along with ligamentum flavum buckling contributes to severe canal narrowing. There is moderate bilateral neuroforaminal narrowing.

At L4-L5, disc bulge along with ligamentum flavum buckling contributes to mild canal narrowing. There is severe bilateral neuroforaminal narrowing with nerve root compromise.

At L5-S1, Central extrusion with annular fissure indents the ventral thecal sac. No spinal canal narrowing. There is severe bilateral neuroforaminal narrowing with nerve root compromise.

Included retroperitoneal structures are unremarkable.

Impression: Multilevel degenerative change with congenital narrowing of the spinal canal. Severe spinal canal narrowing seen at L3-L4. Extrusion noted at L5-S1. Severe neuroforaminal narrowing seen at L4-L5 and L5-S1 as discussed.

Dictated on: 11/9/2021 8:05 AM
Interpreted by: Kevin Liaw, M.D.
Transcribed by: Powerscribe 360
Signed by: Kevin Liaw, M.D.