Medical Record Procedure Assignment Help: How to Answer This Question

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Original Question

MEDICAL RECORD PROCEDURE: MRI LUMBAR SPINE WITHOUT CONTRAST Location: Spectrum Pain Clinic (Global) Sex: Female Age: 62 DOS: 1/1/20XX COMPARISON: None. INDICATIONS: Lower back pain. Question degenerative disc disease. TECHNIQUE: Sagittal T1, TSE T2, STIR; axial TSE T2 images parallel to the disc spaces; coronal TSE T2 weighted. FINDINGS: CONUS MEDULLARIS: Normal in appearance, terminating at L1-2. PARASPINAL AREA: Normal. BONES: Lumbar vertebral bodies are in alignment. Vertebral body height and marrow signal intensity are unremarkable. LUMBAR DISC LEVELS L1-L2: Normal for age. L2-L3: Normal for age. L3-L4: Normal for age. L4-L5: Disc height is mildly diminished. Decreased signal intensity is seen internally on T2-weighted images. There are facet degenerative changes. The canal is widely patent. No mass effect is seen on the exiting nerve roots. Best seen on the sagittal views along the posterior aspect of the right facet, there is a tiny 1-2 mm hyperintense focus on the STIR and T2-weighted images, felt to represent a tiny synovial cyst off the posterior facet margin. L5-S1: Disc height is maintained. Decreased signal intensity internally on T2-weighted images. There are more advanced facet degenerative changes and hypertrophy. This extends slightly into the neuroforamina, but I see no obvious mass effect on the exiting nerve roots. This, however, appears possibly to abut the exiting nerve root on the left. CONCLUSION: 1. Mild discogenic disease at L4-5 with slight loss of height. 2. Facet degeneration and hypertrophy at L5-S1 resulting in mild left greater than right narrowing, but it does not appear to displace the exiting nerve roots. Electronically signed by 1/1/20XX

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