Non-Contrast Abdominal CT 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 radiculopathy. Rule out herniated disc or spinal stenosis.  
  
Technique:  
MRI of the lumbar spine was performed without contrast using standard T1 and T2-weighted sequences in sagittal and axial planes.  
  
Findings:  
- Alignment: Normal lumbar lordosis is maintained. No evidence of spondylolisthesis.  
- Vertebrae: Mild degenerative changes noted with decreased signal intensity on T2-weighted images at L4-L5 and L5-S1 levels.  
- 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 neural foraminal narrowing.  
  - L5-S1: Moderate disc herniation with impingement on the right S1 nerve root.  
- Spinal Canal: No evidence of spinal canal stenosis.  
- Soft Tissues: Paraspinal soft tissues appear unremarkable.  
  
Impression:  
1. Moderate disc herniation at L5-S1 with impingement on the right S1 nerve root, correlating with the patient's symptoms of radiculopathy.  
2. Mild degenerative disc disease at L4-L5 and L5-S1.  
3. No significant spinal canal stenosis or spondylolisthesis.  
  
Recommendations:  
Clinical correlation is advised. Consideration for referral to a spine specialist for further evaluation and management. Physical therapy and pain management may be beneficial.  
  
Radiologist: Dr. Emily Carter  
Date of Report: 10/21/2023