Radiology Report Lumbar Explained for Students (Easy Guide)

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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 MRI (magnetic resonance imaging) CLINICAL SYMPTOMS: Herniated disc, recent surgery MAGNETIC RESONANCE EXAMINATION OF THE LUMBAR SPINEwas performed utilizing a combination of T1 (thoracic vertebra 1), gradient echo, and fast spin- echo (fat suppressed) T2-weighted sequences. Appropriate sequences were also performed following intravenous infusion of contrast material. The patient has had multiple surgical procedures with surgery at almost every level in the lumbar region from L1-2 (first lumbar vertebra-second) to L4-5. Unfortunately, the patient was moving during the acquisition of some sequences. At L1-2, there does appear to be abnormal soft-tissue mass to the left of midline, with compression on the dural sac. It certainly has the appearance of disc herniation. However, one also needs to realize that large disc herniation can appear very similarly following surgery as it did prior to surgery, even with removal of the disc. At L2-3 and L3-4, I believe there has been entry to the spinal canal on the left. There is bulging of the intervertebral disc, and there are underlying bone bars at both levels, and there is indentation of the dural sac, but I doubt that there is evidence of overt disc herniation at this time. I do not feel there is significant stenosis, although the dural sac is small at both levels. I believe there has been previous satisfactory decompression. At L4-5, I believe there is significant spinal stenosis circumferentially. There might also be a small disc herniation at L4-5 to the left of midline. I do not believe there is significant abnormality directly at L5-S1. IMPRESSION: The patient has had multiple surgical procedures. She had recent very extensive surgery. Essentially, there does appear to be residual disc herniation at L1-2 to the left of midline. As noted above, it needs to be remembered that an appearance of large disc herniation might not change in the immediate postoperative period, even though the disc has been removed. This would not explain the right lower extremity pain. Continued spinal stenosis at L4-5 with possible small disc herniation to the left of midline. Previous decompression at L2-3 and L3-4. I believe decompression is satisfactory. I do not believe there is evidence of disc herniation at these levels. I do not believe there is significant abnormality at L5-S1. SERVICE CODE(S): ICD-10-CM DX CODE(S):

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