1^MRI LUMBAR SPINE W/O CONTRAST^DOLAN,THOMAS ARTHUR
Group ID# 167089750
_______________________________________________________________________________
DOLAN,THOMAS ARTHUR  311-62-4055    DOB-MAR 11, 1955 M   
Exm Date: MAY 11, 2023@14:20
Req Phys: ANG,DAVID P                    Pat Loc: MONT-PH-PACT-TEAM2 (Req'g Loc)
                                         Img Loc: DRC-MRI
                                         Service: Unknown

 

(Case 640-051123-1728 COMPLETE)MRI LUMBAR SPINE W/O CONTRAST    (MRI  Detailed) CPT:72148
     Reason for Study: h/o L5 disc extrusion

    Clinical History:
      History and Reason for Exam: 
       mri at stanford 11/2/2021 left lateral disc extrusion with mass
      effect on left 
       L5 nerve root, likely chronic.  f/u mri for possible
      neurosurgery referral.  
       
      FOR URGENT EXAMS, page the radiologist on call or phone MRI at
      65677.  
       
      IF SEDATION IS USED, PATIENT MUST ARRIVE WITH A RESPONSIBLE ADULT
      DRIVER.  FAILURE TO DO THIS MAY RESULT IN PATIENT BEING ADMITTED
      TO THE ORDERING SERVICE.  

    Report Status: Verified                   Date Reported: MAY 11, 2023
                                              Date Verified: MAY 11, 2023
    Verifier E-Sig:/ES/ARIAN MASHHOOD, MD

    Report:
      MRI LUMBAR SPINE WITHOUT CONTRAST:    
       
      CLINICAL HISTORY: "h/o L5 disc extrusion" 
       
      COMPARISON: MRI lumbar spine 6/26/2018     
       
      PROCEDURE COMMENTS: Multiplanar multisequence MRI of the lumbar
      spine was performed without IV contrast at 3 Tesla.  
       
      FINDINGS: 
       
      Anatomy: Counting from C2, there are five lumbar type vertebral
      bodies. The last well-formed disc is labeled as L5-S1.  
       
      Localizer image: C4 superior endplate compression deformity,
      incompletely characterized.  
       
      Alignment: Grade 1 anterolisthesis L3-L4 and L4-L5. Approximately
      5 mm retrolisthesis L5-S1.  
       
      Vertebrae: Vertebral body heights are preserved. The posterior
      elements are intact. No fracture.  
       
      Bone marrow: No suspicious marrow signal intensity.  
       
      Intervertebral discs: Multilevel disc desiccation and disc space
      height loss. 
       
      Visible cord and cauda equina: Conus medullaris terminates at L1.
      Normal signal and morphology of the cauda equina nerve roots.  
       
      The following axial levels are evaluated: 
       
      T12-L1: Mild bilateral facet hypertrophy. Trace disc bulge. No
      significant spinal canal or neural foraminal stenosis.  
       
      L1-L2: Mild bilateral facet hypertrophy. Trace disc bulge. No
      significant spinal canal or neural foraminal stenosis.  
       
      L2-L3: Circumferential disc bulge. Bilateral facet and
      ligamentous hypertrophy.  Right facet joint effusion. Prominent
      dorsal epidural fat pad. Mild spinal stenosis. Mild left neural
      foraminal stenosis.  
       
      L3-L4: Circumferential disc bulge. Bilateral facet and
      ligamentous hypertrophy.  Prominent dorsal epidural fat pad. No
      significant spinal stenosis. Mild bilateral neural foraminal
      stenosis, greater on the left.  
       
      L4-L5: Circumferential disc bulge. Bilateral facet and
      ligamentous hypertrophy.  No significant spinal stenosis. Mild
      bilateral neural foraminal stenosis.  
       
      L5-S1: Circumferential disc osteophyte with a focal left
      foraminal component.  Bilateral facet hypertrophy. No significant
      spinal stenosis. Mild left neural foraminal stenosis.  
       
      Soft tissues: Fatty infiltration of the paraspinal muscles.  
       
      Abdominal aortic aneurysm: Absent.  
       
      Other: Right greater than left sacroiliac joint degenerative
      change.  
        
      

    Impression:
       
       
      1.  Multilevel degenerative change of the lumbar spine, most
      prominent at L2-L3, where there is mild spinal stenosis and mild
      left neural foraminal narrowing.  
       
      2.  No disc extrusion, as clinically queried.  
       
      Some imaging findings are common, even in normal, pain-free
      volunteers. Among people above the age of 60 who do not have back
      pain, an MRI will find that about: 9 in 10 have disc
      degeneration, 9 in 10 have disc signal loss or desiccation, 8 in
      10 have disc height loss, 8 in 10 have a disc bulge, 4 in 10 have
      a disc protrusion, 4 in 10 have an annular fissure, 4 in 10 have
      facet degeneration, and 3 in 10 have spondylolisthesis.  

    Primary Diagnostic Code: MINOR ABNORMALITY
    Secondary Diagnostic Codes: 
      ABDOMINAL AORTIC ANEURYSM NOT PRESENT

Primary Interpreting Staff:
  ARIAN MASHHOOD, MD, STAFF PHYSICIAN, RADIOLOGY (Verifier)
/AEM


** END REPORT May 20, 2023 8:25:26 am **