Pediatric X-Ray Left Thumb - 3 View Analysis 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. The symptoms have persisted for over six 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 alignment of the lumbar spine is observed.  
- Vertebral Bodies: No evidence of fracture or bone marrow edema. Mild degenerative changes are noted 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 protrusion 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.  
- Paraspinal Soft Tissues: Unremarkable.  
  
Impression:  
1. Moderate disc protrusion at L5-S1 with impingement on the right S1 nerve root, correlating with the patient's symptoms of right leg numbness.  
2. Mild degenerative changes at L4-L5 and L5-S1.  
  
Recommendations:  
Consider referral to a spine specialist for further evaluation and management. Potential options may include epidural steroid injection or surgical consultation if symptoms persist.  
  
Radiologist: Dr. Emily Carter  
Date of Report: October 16, 2023