ke/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzanti Goalmn / F / 85 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

H/O backache radiating to BLE since 3-4 years.
Alleged H/O fall 1 month back with weakness of BLE since then.

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 scoliosis of the lumbar spine with convexity to the
left. There is clockwise rotational anomaly of the upper lumbar vertebrae.

There is left lateral subluxation of the L3 vertebra over the L4 vertebra.

A posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. A disc portion is seen within the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root. There is ligamentum flavum hypertrophy at this level.

A small posterior disc herniation is seen to indent the thecal sac and narrowing both neural foramina at the L3-L4 level. Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4 and L4-L5 levels.

A diffuse posterior disc bulge is seen at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.
..2/.



The lumbar facet joints show degenerative changes.

Small bilateral postero-lateral disc bulges are noted at the L2-L3 level.

The lumbar intervertebral discs show loss of water content.

The lumbar vertebral bodies reveal normal signal intensity. 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 :

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

IMPRESSION :

1. Scoliosis of the lumbar spine with convexity to the
left.

2. Left lateral subluxation of the L3 vertebra over the L4 vertebra.

3. A posterior disc herniation at the L4-L5 level with ligamentum flavum hypertrophy at this level. A disc fragment is seen within the left lateral recess of the L5 vertebra.

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

5. A diffuse posterior disc bulge at the L5-S1 level.

6. Small bilateral postero-lateral disc bulges at the L2-L3 level.

7. Facetal arthropathy in the lumbar region.