Contrast-Enhanced CT Scan of Abdomen and Pelvis for Trauma: Negative Findings Template

Radiology Report  
  
Patient Name: John Doe  
Patient ID: 123456  
Date of Birth: 01/15/1975  
Date of Examination: 10/20/2023  
  
Referring Physician: Dr. Jane Smith  
Examination: MRI of the Lumbar Spine  
  
Clinical Indication:  
Chronic lower back pain with intermittent radiculopathy in the left leg. Rule out disc herniation or spinal stenosis.  
  
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 lumbar lordosis is maintained. No evidence of spondylolisthesis.  
- Vertebral Bodies: Normal height and signal intensity of the vertebral bodies. No fractures or lesions identified.  
- Intervertebral Discs:  
  - L1-L2, L2-L3, L3-L4: No significant disc bulge or herniation.  
  - L4-L5: Mild disc bulge with slight effacement of the thecal sac. No significant neural foraminal narrowing.  
  - L5-S1: Moderate disc herniation with impingement on the left S1 nerve root.  
- Spinal Canal and Neural Foramina:  
  - No significant spinal canal stenosis at any level.  
  - Mild narrowing of the left neural foramen at L5-S1 due to disc herniation.  
- Other Findings: No abnormal signal in the conus medullaris or cauda equina.  
  
Impression:  
1. Moderate disc herniation at L5-S1 with impingement on the left S1 nerve root, correlating with the patient's symptoms of left leg radiculopathy.  
2. Mild disc bulge at L4-L5 without significant neural compromise.  
3. No evidence of significant spinal canal stenosis.  
  
Recommendations:  
Clinical correlation is advised. Consideration for neurosurgical consultation if symptoms persist or worsen. Physical therapy and pain management may be beneficial.  
  
Radiologist: Dr. Emily Carter  
Date of Report: 10/21/2023