Name:

Patient ID:
History:
Date of Birth:
Study: MRI lumbar spine without contrast
Facility:
Physician: XXXXX XXXXX, MD
Date of Service: xx/xx/xxxx xx:xx:xx

PROCEDURE: MRI lumbar spine without contrast

REASON FOR EXAM: Male, 49 years old. Low back pain bilateral leg pain for one year. History of lifting injury 5 years
ago with ablation surgery 4 years ago.

TECHNIQUE: Standardized fat and water weighted pulse sequence were obtained in the axial planes.

COMPARISON: None

FINDINGS: T11-12: Sagittal imaging only. Normal disc height and hydration, minimal anterior endplate spondylosis and
no posterior annular disc bulge/protrusion. Facet arthrosis greater on the left with mild to moderate left and minimal
right non-compressive neural foraminal narrowing. Normal central canal (T2 sagittal series image 5, 7, and 10).

T12-L1: Sagittal imaging only. Minimal anterior endplate spondylosis. Normal disc height, hydration and morphology.
Normal bilateral facet joints. Normal central canal and lateral recesses. Normal bilateral intervertebral neural foramina.

Normal lumbar lordosis. There is no substantial scoliosis. Normal conus medullaris that terminates at the L1 level.

L1-2: Anterior endplate spondylosis. Normal disc height, hydration and morphology. Minimal facet arthrosis (T1 and T2
axial series image 2.) Normal central canal and bilateral lateral recesses. Normal bilateral intervertebral neural formina.

L2-3: Normal disc height and hydration, minimal anterior endplate spondylosis and subtle posterior annular disc bulge
flattening the ventral thecal sac. Minimal facet arthrosis and normal neural foramina. Normal central canal (T1-T2 axial
series image 5).

L3-4: Normal disc height and hydration, minimal anterior endplate spondylosis, and posterior annular disc bulging
flattening the ventral thecal sac. Mild facet arthrosis, minimal ligamentous hypertrophy, mild left and minimal right
non-compressive neural foraminal narrowing. Borderline low normal sagittal size of the thecal sac and normal lateral
recesses (T1 and T2 axial series image 9).

L4-5: Minial decreased disc height, disc desiccation, anterior spondylosis with anterior disc protrusion which is not
impinging neural structures, subtle spondylolisthesis with 2mm of anterolisthesis of L4 in relationship to L5, and
uncovering of the disc with broad-based disc hemiation of the protrusion type measuring less than 3mm (AP) with
annular tear. There is flatting of the ventral thecal sac and impingement of the L5 nerve roots. Severe facet arthrosis,
possible tiny 2mm right facet synovial cyst impinging the right L5 nerve root, ligamentous hypertrophy contouring
the posterior lateral thecal sac, and mild to moderate left greater than right neural foraminal narrowing with potential
neural impingement on the left. Narrowing of the thecal sac to 7 mm sagittally with prominent dorsal epidural fat and
severe narrowing the lateral recesses greater on the right (T1 and T2 axial series image 13-15).

© 2013 Radisphere
L5-S1: Normal disc height, disc desiccation, anterior endplate spondylosis and posterior annular disc bulge. Mild facet
arthrosis with low volume facet effusions and mild non-compressive neural foraminal narrowing. Normal central canal
and lateral recesses (T1 and T2 axial series image 18 and 19).
Normal visualized sacral ala.

Normal visualized paraspinous soft tissue structures.

IMPRESSION:
Multilevel degenerative changes, as described above greatest and severe at L4-5. Multiple level ligamentous
hypertrophy as described.

L4-5 moderate central stenosis, subtle spondylolisthesis, broad-based disc protrusion with annular tear, possible tiny
right facet synovial cyst, impingement of the L5 nerve roots greater on the right, potential impingement of the exiting
left L4 nerve root.

L2-3, L3-4 and L5-S1 annular disc bulge.

© 2013 Radisphere