Right Hand X-Ray with Two Views 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 radiating to the left leg, with a history of lumbar disc herniation. The examination is requested to evaluate for any degenerative changes or nerve root compression.  
  
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.  
- Vertebrae: Mild degenerative changes are noted with endplate sclerosis at L4-L5 and L5-S1. No vertebral body fracture or marrow edema is observed.  
- 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 and mild bilateral foraminal narrowing.  
  - L5-S1: Disc desiccation with a broad-based disc bulge causing moderate left foraminal stenosis and impingement of the exiting left L5 nerve root.  
- Spinal Canal and Neural Foramina: No significant central canal stenosis. Mild bilateral foraminal narrowing at L4-L5 and moderate left foraminal stenosis at L5-S1.  
- Paraspinal Soft Tissues: Unremarkable.  
  
Impression:  
1. Moderate left foraminal stenosis at L5-S1 with impingement of the exiting left L5 nerve root, correlating with the patient's symptoms of left leg radiculopathy.  
2. Mild degenerative changes at L4-L5 with mild bilateral foraminal narrowing.  
3. No evidence of acute fracture or significant central canal stenosis.  
  
Recommendations:  
Clinical correlation is advised. Consideration for referral to a spine specialist for further evaluation and management, including potential physical therapy or interventional procedures.  
  
Radiologist: Dr. Emily Carter  
Date of Report: October 16, 2023