Radiology Report Lumbar Assignment Help: How to Answer This Question

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Original Question

Radiology Report, Lumbar Spine MRI LOCATION: Inpatient, Hospital PATIENT: Sara Vasek ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD RADIOLOGIST: Grey Lonewolf, MD EXAMINATION OF: Lumbar spine MRI (magnetic resonance imaging) CLINICAL SYMPTOMS: Herniated disc LUMBAR SPINE MRI WITH and WITHOUT CONTRAST: TECHNIQUE: T1 (thoracic vertebra 1), T2, and fat-saturated postcontrast T1 sagittal images were acquired. T1, T2, and postcontrast T1 axial images were acquired from L1 (first lumbar vertebra) to S1 (first sacral vertebra). No prior studies are provided for comparison. FINDINGS: The conus is normal. The T11-12 disc space is desiccated with an inferior endplate Schmorl’s node and mild anterior spurring. The T12-L1 disc space is unremarkable. At L1-2, there is a peripherally enhancing left anterolateral epidural soft- tissue process. A left laminotomy with a peripherally enhancing fluid collection is noted. The disc space is desiccated with bulging. There is no enhancement abnormality within the disc space. At L2-3, there is a left laminotomy, facetectomy, and foraminotomy with a peripherally enhancing fluid collection in the surgical bed. Enhancing epidural and perineural tissues are noted. Sagittal images show some bright enhancing T2 signal in the left hemisphere of the disc space, without associated endplate changes. Within the left lateral recess of L3 is a peripherally enhancing collection having long T1/long T2 signal. For example, compare postcontrast axial image #16 with T2-weighted axial image #16 and precontrast image #16. At L3-4, there is a left laminectomy and inferior facetectomy with enhancing granulation tissue in the surgical bed. The disc space is desiccated with bulge and mild spurring. At L4-5, there is a left laminectomy and partial facetectomy with enhancing epidural granulation tissue. Right ligamentum flavum is redundant. Right lateral recess is moderately to markedly stenotic. Moderate to marked degenerative disease is present in the right facet joint. Right neural foramen is moderately to markedly stenotic. The left neural foramen is amply patent. At L5-S1, there is advanced bilateral degenerative facet disease with disc desiccation with bulge. IMPRESSION: 1. Left laminectomies and/or facet postoperative changes including L1-2 through L4-5. 2. Peripherally enhancing mass in the left L3 lateral recess has indeterminate etiology. Given findings of recent surgery, packing material or postoperative fluid collection is considered. A free fragment of peripherally enhancing disc material could have a similar appearance. 3. Enhancing in the left hemisphere of the L2-3 disc space in conjunction with bright T2 signal intensity may represent postoperative change. 4. Multilevel degenerative disc disease. 5. Moderate to marked right L4-5 foraminal stenosis. 6. Peripherally enhancing soft tissue at the dorsal aspect of the L1-2 disc space has uncertain significance. This finding likely represents acute postoperative change; however, clinical correlation is suggested. Acute postoperative change has been described in the literature as mimicking residual or recurrent disc herniation. SERVICE CODE(S): ______________________________________ ICD-10-CM DX CODE(S):

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