sb/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzon Hathlmn / M / 50 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 8 months.
C/O radicular pain to BLE with paresthesias since 2 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 sacralization of the L5 vertebra and the L3 vertebral body is as marked on the film.

There is slight retroplacement of the L3 over the L4 vertebra.

There is loss of water content of all the lumbar intervertebral discs except the L5-S1 disc.

There is a fairly large, postero-central and left paracentral extruded disc with peridiscal osteophytes at the L3-L4 level with thecal sac compression. A part of the disc fragment is noted in the left lateral recess of L4 vertebra, impinging the traversing left L4 nerve root. Facetal arthropathy is noted at this level.

A posterior and right postero-lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with right neural foraminal narrowing and probable indentation on the extraforaminal segment of the right L4 nerve root. Facetal hypertrophy is noted at this level.
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Small postero-central protruded discs with peridiscal osteophytes are noted at the D12-L1, L1-L2 and L2-L3 levels, indenting the dural theca anteriorly.

Type II degenerative marrow changes are noted adjacent to the L3-L4 and L4-L5 intervertebral discs.

Schmorls nodes are identified from the D11 to the L3 vertebral levels.

Facetal hypertrophy is noted in the lower lumbar region.

The remaining lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.

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
13.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. Slight retroplacement of the L3 over the L4 vertebra.

3. A fairly large, postero-central and left paracentral extruded disc with peridiscal osteophytes at the L3-L4 level with a part of the disc fragment in the left lateral recess of L4 vertebra, impinging the traversing left L4 nerve root.
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4. A posterior and right postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with probable indentation on the extraforaminal segment of the right L4 nerve root.

5. Small postero-central protruded discs with peridiscal osteophytes at the D12-L1, L1-L2 and L2-L3 levels,

6. Canal stenosis at the L3-L4 and L4-L5 levels.