sb/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzB. lmn / M / 60 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE since 8 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 loss of water content of lumbar (more so at the L3-L4 and L4-L5 levels) intervertebral discs. Slight retroplacement of the L4 over the L5 vertebral body is noted.

There is a fairly large, postero-central, right far lateral and postero-lateral extruded discs with peridiscal osteophytes at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Inferior migration of the disc fragment is noted in the anterior epidural space and right lateral recess of L5, with impingement of the traversing L5 nerve roots bilaterally. There is also indentation on the extraforaminal segment of the right L4 nerve root. Facetal hypertrophy with facet joint effusion is noted at the L4-L5 level bilaterally.

A small, postero-central disc herniation is noted at the L3-L4 level with slight inferior migration of the disc fragment indenting the dural theca anteriorly. Bilateral far lateral (extraforaminal) disc bulges are noted at this level.


A small postero-central protruded disc is noted at the D12-L1 level.

A probable left sided conjoint nerve root is noted at the L5-S1 level.

The lumbar vertebral bodies 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 S1 level.

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

18.0 mm at L1-L2
18.0 mm at L2-L3
14.0 mm at L3-L4
10.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

1. A fairly large, postero-central, right postero-lateral and far lateral extruded discs with peridiscal osteophytes at the L4-L5 level with inferior migration of the disc fragment in the anterior epidural space and right lateral recess of L5 impinging the traversing L5 nerve roots bilaterally. There is also indentation on the extraforaminal segment of the right L4 nerve root.

2. Facetal hypertrophy and facet joint effusion at the L4-L5 level bilaterally.

3. A small, postero-central disc herniation at the L3-L4 level with slight inferior migration of the disc fragment.