Non-Contrast CT Scan of the Female Pelvis 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 History:  
The patient presents with chronic lower back pain radiating to the left leg, with numbness and tingling. Symptoms have persisted for the past three months, with no significant relief from physical therapy or medication.  
  
Technique:  
Magnetic Resonance Imaging 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:  
  - L3-L4: Mild disc bulge without significant canal or foraminal stenosis.  
  - L4-L5: Moderate disc protrusion with mild effacement of the thecal sac. Mild bilateral foraminal narrowing noted.  
  - L5-S1: Large left paracentral disc herniation impinging on the left S1 nerve root, correlating with the patient's symptoms.  
- Spinal Canal and Neural Foramina: No significant central canal stenosis. Mild bilateral foraminal narrowing at L4-L5.  
- Conus Medullaris: Terminates at the L1 level, normal in appearance.  
- Soft Tissues: No abnormal soft tissue masses or signal abnormalities.  
  
Impression:  
1. Large left paracentral disc herniation at L5-S1 impinging on the left S1 nerve root, correlating with the patient's left leg radiculopathy.  
2. Moderate disc protrusion at L4-L5 with mild bilateral foraminal narrowing.  
3. Mild disc bulge at L3-L4 without significant stenosis.  
  
Recommendations:  
Consider referral to a spine specialist for further evaluation and management, including potential surgical consultation given the severity of the disc herniation and persistent symptoms.  
  
Radiologist: Dr. Emily Carter  
Date of Report: 10/21/2023