sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzali Khilalmn / M / 75 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias.

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 the lumbar intervertebral discs.

There is a small, postero-central protruded disc with peridiscal osteophytes at the L5-S1 level. Slight facetal hypertrophy is also noted at this level.

A fairly large posteriorly herniated disc with peridiscal osteophyte is noted at the L4-L5 level with thecal sac compression. A sequestered disc fragment is noted in the right antero-lateral epidural space at the L4 vertebral level, compressing the thecal sac and the traversing right L4 nerve root. There is also facetal and ligamentum flavum hypertrophy at the L4-L5 level with canal stenosis.

There is a posterior and left postero-lateral peridiscal osteophyte at the L3-L4 level with slight left neural foraminal narrowing.


Type II degenerative marrow changes are noted adjacent to the L2-L3, L4-L5 and L5-S1 intervertebral discs. Slight irregularity of the cortical endplates adjacent to the L3-L4 and L4-L5 intervertebral discs is noted which may be due to degenerative changes.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L2 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 :

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

Screening, T2 Weighted sagittal images of the lower cervical and dorsal spines do not reveal any significant feature of note.

IMPRESSION :

1. A small, postero-central protruded disc with peridiscal osteophytes at the L5-S1 level with slight facetal hypertrophy at this level.

2. A fairly large posteriorly herniated disc with peridiscal osteophyte at the L4-L5 level with a sequestered disc fragment in the right antero-lateral epidural space at the L4 vertebral level, compressing the traversing right L4 nerve root. There is also facetal and ligamentum flavum hypertrophy at the L4-L5 level with canal stenosis.

3. A posterior and left postero-lateral peridiscal osteophyte at the L3-L4 level.