Non-Contrast CT Scan of Abdomen and Pelvis for Trauma: Negative Results 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 is a 45-year-old male presenting with chronic lower back pain radiating to the left leg. Symptoms have persisted for over three months, with intermittent numbness and tingling in the left foot. No history of trauma reported.  
  
Technique:  
MRI of the lumbar spine was performed using standard protocol. Sagittal T1, T2, and STIR sequences, as well as axial T2-weighted images, were obtained.  
  
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: The spinal canal is of normal caliber. Mild narrowing of the left neural foramen at L5-S1.  
- 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:  
Clinical correlation is advised. Consideration for neurosurgical consultation for further management of the L5-S1 disc herniation. Physical therapy may be beneficial for symptom management.  
  
Radiologist: Dr. Emily Carter  
Date of Report: October 16, 2023