ke/bv/rg.
/51 Date : 00.00.00

Name of the Patient : Abc Xyzilmn / M / 72 yrs.
Referred by : Dr. Abc Xyzkim.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O severe backache radiating to BLE (left more than right) since 3 days.

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.

SOME IMAGES SHOW PATIENT MOTION AS PATIENT WAS IN SEVERE PAIN AND EXAMINATION WAS DONE UNDER SEDATION.

OBSERVATION :

There is sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.

The lumbar intervertebral discs except for the L4-L5 and L5-S1 discs show loss of water content.

There is slight forward translation of the L4 over the L5 vertebra with a large left paracentral disc herniation at the L4-L5 level with indentation upon the foraminal left L4 nerve root. There is superior migration of the disc which is seen to lie posterior to the L4 vertebral body. There is left facetal arthropathy with ligamentum flavum hypertrophy with left lateral recess stenosis.

A small posterior disc bulge is seen at the L3-L4 level.

Anterior disc herniations with peridiscal osteophytes are noted over the L2-L3 to L5-S1 levels as well as the lower dorsal region. ..2/.


- 2 - scan-00006

Hemangioma with fatty content is seen in the L4 and L5 vertebral bodies and focal fatty changes in the L2 and L5 vertebral bodies.

The lumbar facet joints show slight degenerative changes. Mild ligamentum flavum hypertrophy is also seen at the L3-L4 level.

The rest of the lumbar vertebral bodies normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 level and the thecal sac terminates at the S1 level.

A right renal cyst is noted.

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

20.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Sacralization of the L5 vertebra.

2. Slight forward translation of the L4 over the L5 vertebra with a large left paracentral disc herniation at the L4-L5 level with superior migration of the disc seen to lie posterior to the L4 vertebral body with left facetal arthropathy and ligamentum flavum hypertrophy with left lateral recess stenosis and indentation upon the foraminal left L4 nerve root.

3. A small posterior disc bulge at the L3-L4 level.

4. Slight facetal arthropathy in the lumbar region.