MRI EXAMINATION OF THE LUMBAR SPINE WITH AND WITHOUT CONTRAST

MRI EXAMINATION OF THE LUMBAR SPINE WITH AND WITHOUT CONTRAST

INDICATION FOR STUDY:           Pain.  Radiculopathy.

FINDINGS:               Prior attempted evaluation with only sagittal T2 weighted images was performed on XXXXXXXX on the 1.5 Tesla GE MRI and prior MRI examination was performed on XXXXXXXX.  Sagittal T1 and T2, axial T1 and T2, and post-contrast sagittal and axial T1 weighted images on the Open MRI were performed.  There is continued evidence of significant degenerative changes and degenerative disc disease at the level of L2-L3.  There is slight offset of the vertebral bodies at L4-L5 of few millimeters.  There is desiccation of the disc.  The conus and nerve roots within the thecal sac show no gross abnormality.  There is no significant abnormal enhancement to the vertebral bodies or thecal sac region.

At the level of L1-L2, there is no significant disc herniation, central canal stenosis, or neuroforaminal narrowing.

At the level of L2-L3, there is degenerative disc disease and disc space loss.  There is indentation on the anterior thecal sac and mild central canal stenosis.  There are degenerative changes of the facet joints and slight disc disease causing left neuroforaminal narrowing.  There is no significant right neuroforaminal narrowing.  There is no significant abnormal enhancement around the thecal sac or neuroforaminal region.  These changes are best seen on image 4 and 5 of series 7.

At the level of L3-L4, there is diffuse disc herniation, degenerative changes, and ligament flavum hypertrophy overall causing mild central canal stenosis.  There is indentation on the exiting nerve roots slightly bilaterally, but no significant impingement.  There is no significant abnormal enhancement around the thecal sac or neuroforaminal regions.

At the level of L4-L5, there are degenerative changes and slight offset of few millimeters as previously discussed.  There is diffuse disc herniation, degenerative changes, and ligament flavum hypertrophy overall causing mild-to-slightly-moderate central canal stenosis, which is also seen previously, but does not appear significantly changed.  There is continued evidence of slight indentation on the exiting nerve roots bilaterally, but no significant impingement, slightly greater on the right than the left.

There is no significant abnormal enhancement around the thecal sac or neuroforaminal regions.

At the level of L5-S1, there is slight indentation on the anterior thecal sac.  There is no significant central canal stenosis or neuroforaminal narrowing.  There are degenerative changes.  There is no significant abnormal enhancement around the thecal sac or neuroforaminal regions.  Overall, the examination does not appear significantly changed compared to previously and would recommend clinical correlation or further evaluation as necessary.  Would recommend reference to the patient’s plain film reports also.

Thank you for the referral.

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