What symptoms are expected from L2‑L3 severe disc height loss with mixed Modic type I/II end‑plate changes and disc desiccation, a left‑eccentric mild diffuse disc bulge with a small right annular disc extrusion that has migrated superiorly 4 mm and indents the right ventral thecal sac, and moderate left and mild right neuroforaminal narrowing?

Expected Symptoms from L2-L3 Degenerative Changes with Disc Extrusion and Neuroforaminal Narrowing

The MRI findings you describe can produce low back pain, right-sided radicular symptoms affecting the L2 nerve root (anterior/medial thigh pain, hip flexor weakness), and left-sided L2 radiculopathy from the moderate left neuroforaminal narrowing, but the presence of unilateral whole-body sensory changes would be incompatible with these isolated lumbar findings and should prompt urgent whole-spine MRI to exclude cervical or thoracic cord pathology. 1

Primary Expected Symptoms from L2-L3 Pathology

Axial Low Back Pain

• Chronic low back pain is the predominant symptom associated with severe disc height loss and mixed Modic type I/II endplate changes 2, 3
• Modic type I changes (representing fibrovascular tissue and edema) are strongly associated with low back pain, with prevalence of 18-58% in symptomatic patients versus only 12-13% in asymptomatic individuals 2
• The combination of Modic changes, decreased disc height, and disc desiccation predicts persistent or worsening pain in approximately 36% of patients during one-year follow-up 3
• Mixed type I/II changes suggest an active degenerative process that may cause more significant symptoms than isolated findings 3

Right-Sided L2 Radiculopathy (from disc extrusion)

• Anterior and medial thigh pain radiating from the groin toward the knee, as the L2 nerve root supplies sensation to this distribution 4
• Hip flexor weakness (iliopsoas muscle), making it difficult to lift the thigh while sitting or climbing stairs 4
• Numbness or paresthesias along the anterior/medial thigh 4
• The 4 mm superior migration of the disc fragment with right ventral thecal sac indentation can compress the exiting or traversing L2 nerve root 4

Left-Sided L2 Radiculopathy (from moderate neuroforaminal narrowing)

• Similar distribution of pain affecting the left anterior/medial thigh, though potentially less severe than the right side given the moderate versus mild narrowing 4
• Left-sided symptoms may be more chronic and positional, worsening with lumbar extension that further narrows the neural foramen 4
• The left-eccentric disc bulge contributes to the moderate left neuroforaminal compromise 4

Critical Red Flag Consideration

When Symptoms Don't Match the Imaging

• Unilateral whole-body sensory changes are NOT compatible with a single L2-L3 disc pathology and should raise immediate suspicion for cervical or thoracic spinal cord compression 1
• Progressive neurologic deficits developing over 2 days constitute a red-flag emergency requiring urgent whole-spine MRI without contrast 1
• Hemibody sensory involvement indicates a lesion above the lumbar level, not a peripheral radiculopathy from lumbar disc disease 1
• Do not attribute extensive neurologic symptoms to an incidental lumbar disc bulge—disc bulges are frequent incidental findings and rarely produce such widespread symptoms 1
• Delayed diagnosis of spinal cord compression results in significantly worse neurological outcomes and permanent deficits 1

Symptom Patterns and Natural History

Pain Characteristics

• Discogenic pain from annular tears and disc disruption is present in most disc protrusions and bulges (80-100% show Stage 2-3 annular disruptions on discography) 5
• Loss of disc height and abnormal signal intensity are highly predictive (>80%) of symptomatic tears extending into or beyond the outer annulus 5
• Pain may improve within 4 weeks with conservative management in younger patients with acute disc herniations as the inflammatory process resolves 6
• However, persistent Modic type I changes, decreasing disc height, and increasing endplate irregularities predict persistent pain rather than improvement 3

Neurologic Symptoms

• Nerve root compression symptoms depend on the specific anatomic compromise: the right-sided disc extrusion likely causes more acute radicular pain, while the left neuroforaminal narrowing may produce more chronic, positional symptoms 4
• Mild right neuroforaminal narrowing may be asymptomatic or produce minimal symptoms compared to the moderate left-sided narrowing 4

Common Pitfalls to Avoid

• Do not assume all symptoms are explained by the L2-L3 findings if the clinical presentation includes bilateral symptoms, bowel/bladder dysfunction, or symptoms above the L2 dermatome 1
• Do not delay imaging if red-flag features are present—immediate whole-spine MRI is required for progressive deficits or multifocal neurological involvement 1
• Do not limit evaluation to the lumbar spine alone when symptoms suggest a more rostral lesion; comprehensive neuraxis imaging is essential 1
• Recognize that severe disc degeneration is not an isolated event but associated with vertebral endplate changes and paraspinal muscle fatty infiltration, which may contribute to symptom severity 7
• The presence of Modic changes and disc degeneration does not automatically indicate the disc is the pain generator, as these findings can be present in asymptomatic individuals 2