hs/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzi Birwalmn / F / 69 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 15 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.

OBSERVATION :

There is retroplacement of the L5 vertebra over the S1 vertebra and mild forward listhesis of the L4 vertebra over the L5 vertebra.

A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina (left more than right) at the L5-S1 level. A left far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting left L5 nerve root at this level. Also seen is a small right fat lateral (extraforaminal) disc herniation at this level. Slight superior migration of the disc fragment, on the left is noted.

There is a postero-central disc herniation indenting the thecal sac at the L4-L5 level. A right postero-lateral (foraminal) disc herniation is seen to narrow the right neural foramen at this level. Bilateral (right more than left) far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting L4 nerve roots at the L4-L5 level.
..2/.





There is a small posterior disc herniation causing mild neural foraminal narrowing bilaterally at the L3-L4 level. Posterior disc bulges with small peridiscal osteophytes are noted at the D12-L1, L1-L2 and L2-L3 levels.

The L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes.

The lumbar intervertebral discs show loss of water content. Hypointense areas on all the pulse sequences are evident within the L5-S1 intervertebral disc and this may represent calcium/vacuum phenomena.

Hemangioma with fat content is noted in the L3 vertebral body.

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

The D11 vertebral body is wedged, anteriorly, without change in signal intensity.

The conus medullaris terminates at the D12-L1 level and the thecal sac terminates at the S1 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
15.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Retroplacement of the L5 vertebra over the S1 vertebra and mild forward listhesis of the L4 vertebra over the L5 vertebra.
..3/.




- 3 - Scan-00003



2. A posterior disc herniation with peridiscal osteophytes at the L5-S1 level.

3. A left far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting left L5 nerve root at the L5-S1 level.

4. A small right far lateral (extraforaminal) disc herniation at the L5-S1 level.

5. Postero-central and right postero-lateral (foraminal) disc herniation at the L4-L5 level.

6. Bilateral (right more than left) far lateral disc herniations indenting the extraforaminal portion of the exiting L4 nerve roots at the L4-L5 level.

7. A small posterior disc herniation at the L3-L4 level.