CT Scan of Face and Orbits Without Contrast: Negative Results 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  
Indication: Chronic lower back pain, rule out lumbar disc herniation.  
  
Examination: MRI Lumbar Spine  
  
Technique:  
Multiplanar, multisequence MRI of the lumbar spine was performed without contrast.  
  
Findings:  
- Alignment: Normal lumbar lordosis is maintained. No evidence of spondylolisthesis.  
- Vertebral Bodies: The vertebral bodies are of normal height and signal intensity. No acute fractures or marrow-replacing lesions are identified.  
- Intervertebral Discs:  
  - L1-L2, L2-L3, and L3-L4: No significant disc bulge or herniation.  
  - L4-L5: Mild disc bulge with no significant spinal canal or foraminal stenosis.  
  - L5-S1: Moderate disc protrusion with mild impingement on the right S1 nerve root.  
- Spinal Canal and Neural Foramina: The spinal canal is of normal caliber. Mild narrowing of the right neural foramen at L5-S1.  
- Conus Medullaris: Terminates at the L1 level and appears normal.  
  
Impression:  
1. Moderate disc protrusion at L5-S1 with mild impingement on the right S1 nerve root, correlating with the patient's symptoms of lower back pain.  
2. Mild disc bulge at L4-L5 without significant stenosis.  
3. No acute fracture or significant degenerative changes noted.  
  
Recommendations:  
Clinical correlation is advised. Consideration for conservative management, including physical therapy, and follow-up imaging if symptoms persist or worsen.  
  
Radiologist: Dr. Emily Johnson  
Date of Report: 10/21/2023