Left Thumb X-Ray: Three Views 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 History:  
The patient presents with chronic lower back pain radiating to the left leg, with intermittent numbness and tingling. Symptoms have persisted for approximately 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 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 indentation on the thecal sac. No significant foraminal narrowing.  
  - L5-S1: Moderate disc herniation with impingement on the left S1 nerve root.  
- Spinal Canal and Neural Foramina: The spinal canal is of normal caliber. Mild narrowing of the left neural foramen at L5-S1 due to disc herniation.  
- Paraspinal Soft Tissues: Unremarkable.  
  
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.  
  
Recommendations:  
Consideration for neurosurgical consultation for further evaluation and management of the L5-S1 disc herniation. Conservative management may continue for the L4-L5 disc bulge.  
  
Radiologist: Dr. Emily Carter  
Date of Report: October 16, 2023