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

Radiology Report  
  
Patient Name: John Doe  
Patient ID: 123456  
Date of Examination: October 15, 2023  
Referring Physician: Dr. Jane Smith  
Examination: MRI of the Lumbar Spine  
  
Clinical Indication:  
The patient presents with chronic lower back pain radiating to the left leg, with a history of lumbar disc herniation. The examination is requested to evaluate for any degenerative changes or nerve root compression.  
  
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, and L3-L4 levels show normal disc height and signal.  
  - L4-L5 level demonstrates a mild diffuse disc bulge with no significant spinal canal stenosis.  
  - L5-S1 level shows a moderate left paracentral disc herniation, causing mild compression of the left S1 nerve root.  
- Spinal Canal and Neural Foramina: No significant spinal canal stenosis. Mild narrowing of the left neural foramen at L5-S1 due to disc herniation.  
- Conus Medullaris: Terminates at the L1 level, normal in appearance.  
  
Impression:  
1. Moderate left paracentral disc herniation at L5-S1 with mild compression of the left S1 nerve root, correlating with the patient's symptoms of left leg radiculopathy.  
2. Mild diffuse disc bulge at L4-L5 without 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: October 16, 2023