MRI OF THE LUMBAR SPINE
DATE OF STUDY: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
Comparison is made to an earlier exam.
TECHNIQUE: Multiplanar images were obtained using multiple pulse sequences to the lumbar spine. Because of the postoperative nature of the lumbar spine, additional axial and sagittal postgadolinium T1-weighted images were obtained.
Plain films are not available for comparison; therefore, it will be assumed there is a normal complement of lumbar vertebrae. Scanning was performed on 0.3-Tesla open bore scanner.
FINDINGS: The examination shows lumbar vertebrae to be in normal overall alignment with preservation in vertebral body heights and normal signal within the marrow. For descriptive purposes of this study, fairly small disc is noted at the S1-S2 interspace. The tip of the conus lies near the lower body of L1; we believe this nomenclature is the same as that used on the prior exam.
Transaxial images show postsurgical changes from prior right semi-hemilaminectomy at the S1 vertebra. Examination does show the presence of a small annular disc bulge and perhaps some early annular spurring; however, the traversing S1 nerve roots are unimpeded, and there is no evidence of recurrent focal disc herniation. There is some normal enhancement seen involving the soft tissues, presumably of a postoperative nature.
At the L4-L5 level, there is likewise no evidence of focal disc herniation or significant central spinal stenosis.
The L3-L4 interspace shows trace annular bulging without focal disc herniation or stenosis. L1-L2 and L2-L3 interspaces show a normal appearance on sagittal imaging.
IMPRESSION: MR examination of the lumbar spine with postsurgical changes from previous right semi-hemilaminectomy at L5-S1 level on the right.
While there may be some minimal annular bulging and annular spurring at this level, there is no discrete focal disc herniation, and traversing S1 nerve roots are not compromised.
The remainder of the lumbar interspaces may show some very minimal disc bulging, however, no focal disc herniation or central spinal stenosis. The cause of the patient’s right lower extremity radicular symptoms cannot easily be explained on the basis of findings.
Thank you for your kind referral.
