Non-Contrast Pelvic CT Scan 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 Indication:  
The patient presents with chronic lower back pain and intermittent numbness in the right leg. Symptoms have persisted for over six months, with no significant relief from physical therapy.  
  
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 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.  
- Soft Tissues: No abnormal paraspinal soft tissue masses.  
  
Impression:  
1. Moderate disc herniation at L5-S1 with impingement on the right S1 nerve root, correlating with the patient's symptoms of right leg numbness.  
2. Mild disc bulge at L4-L5 without significant neural compromise.  
  
Recommendations:  
Consider referral to a spine specialist for further evaluation and management, including potential surgical consultation if symptoms persist or worsen.  
  
Radiologist: Dr. Emily Carter  
Date of Report: October 16, 2023