Demographics:
51 years old, Male
Indication:
Left foot numbness, urinary incontinence
Findings
- Large broad-based disc bulge at L5-S1 with superimposed left paracentral inferiorly migrating disc extrusion which contributes to moderate crowding of nerve roots in the thecal sac, effacement of the left subarticular zone, and moderate bilateral neural foraminal stenosis
- Extruded disc material displaces and deforms the descending left S1 nerve roots
- At L2-L3, L3-L4 and L4-L5, broad-based disc bulges, facet hypertrophy, and ligamentum flavum thickening contribute to mild bilateral neural foraminal stenosis without significant spinal canal stenosis
- Degenerative disc disease at T12-L1 and L1-L2 with discogenic endplate degenerative changes. No significant spinal canal or neural foraminal stenosis
- Subcentimeter T2 hyperintense structure in the lower pole of the left kidney, which likely represents a cyst
Diagnosis
Disc herniation
Sample Report
A left paracentral, inferiorly migrating disc extrusion at L5-S1 displaces and deforms the descending left S1 nerve roots. Herniated disc material contributes to moderate crowding of nerve roots in the thecal sac, effacement of the left subarticular zone, and moderate bilateral neural foraminal stenosis.
Otherwise mild multilevel neural foraminal stenosis without significant spinal canal stenosis.
Discussion
References