sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz lmn / F / 35 yrs.
Referred by : Dr. Abc Xyzud.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with tingling since 3 years which increased since 7-8 months.

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 reduction in height and loss of water content of the L2-L3 intervertebral disc. There is spondylolysis at L2, bilaterally, with minimal anterior translation the L2 over the L3 vertebra.

Irregularity of the cortical endplates adjacent to the L2-L3 disc is noted. Ill-defined hypointense signal on all the pulse sequences is noted in the bodies of the L2 and L3 vertebrae adjacent to the L2-L3 disc, suggesting sclerosis. A posteriorly bulging disc with posterior peridiscal osteophytes is noted at the L2-L3 level with bilateral neural foraminal narrowing. Right far lateral disc herniation is also noted indenting the traversing right L2 nerve root. Anterior disc herniation with anterior peridiscal osteophytes is also noted at this level.

Small posterior disc bulges are noted at the L4-L5 and L5-S1 levels.




The rest of 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 :

19.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Changes at the L2-L3 disc level as described above are not specific for a single etiology. These most likely are degenerative in etiology in view of the spondylolysis at L2. The possibility of these changes being due to previous osteitis and discitis seems less likely.

2. Small posterior disc bulges at the L4-L5 and L5-S1 levels.