ke/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzra U. Valmn / M / 64 yrs.
Referred by : Dr. Abc Xyz. Jain.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (left more than right) with tingling.

EXAMINATION :

M.R.I of the lumbo-sacral spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

OBSERVATION :

There is a diffuse posterior disc herniation at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L3-L4 facet joints show hypertrophic degenerative changes with resultant central and lateral canal stenosis. Posterior peridiscal osteophytes are noted at this level.

A posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, left more than right. Facetal arthropathy and ligamentum flavum hypertrophy is noted at this level.

The L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content.

The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions.
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The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

15.0 mm at L1-L2
10.0 mm at L2-L3
6.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. A diffuse posterior disc herniation with posterior peridiscal osteophytes at the L3-L4 level. There is also hypertrophic facetal arthropathy and resultant central and lateral canal stenosis at this level.

2. A posterior disc herniation at the L4-L5 level with facetal arthropathy and ligamentum flavum hypertrophy at this level and canal stenosis.

3. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.