Contrast-Enhanced CT Perfusion Template

Radiology Report  
  
Patient Name: John Doe  
Patient ID: 123456  
Date of Examination: October 15, 2023  
Referring Physician: Dr. Smith  
Examination: MRI of the Lumbar Spine  
  
Clinical History:  
The patient is a 45-year-old male presenting with chronic lower back pain radiating to the left leg. Symptoms have persisted for the past three months, with no significant relief from physical therapy or medication.  
  
Technique:  
MRI of the lumbar spine was performed using standard protocol sequences, including T1-weighted, T2-weighted, and STIR images in sagittal and axial planes.  
  
Findings:  
- Alignment: Normal alignment of the lumbar spine is maintained.  
- Vertebral Bodies: No evidence of fracture or bone marrow edema. Mild degenerative changes are noted with endplate sclerosis at L4-L5.  
- Intervertebral Discs:  
  - L3-L4: Mild disc bulge without significant canal or foraminal stenosis.  
  - L4-L5: Moderate disc protrusion with mild effacement of the thecal sac and mild left foraminal narrowing.  
  - L5-S1: Mild disc degeneration with no significant protrusion or stenosis.  
- Spinal Canal and Neural Foramina: No significant spinal canal stenosis. Mild left foraminal narrowing at L4-L5 as noted.  
- Conus Medullaris: Terminates at the L1 level, normal in appearance.  
- Soft Tissues: No abnormal soft tissue masses or collections.  
  
Impression:  
1. Moderate disc protrusion at L4-L5 with mild left foraminal narrowing, correlating with the patient's symptoms of left leg radiculopathy.  
2. Mild degenerative changes at L4-L5 and L5-S1.  
  
Recommendations:  
Clinical correlation is advised. Consideration for further evaluation with a neurosurgical consultation if symptoms persist or worsen.  
  
Radiologist: Dr. Emily Carter  
Date of Report: October 16, 2023