sb/bv/rg.nl.
Date : 00.00.00

Name of the Patient : Abc Xyzi Shlmn / F / 45 yrs.
Referred by : Dr. Abc Xyznshahi.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias (right more than left) since 2 years.

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 :

The L5 vertebra is as marked on the film.

There is loss of water content of the L1-L2, L2-L3 and L4-L5 intervertebral discs.

A small posterior disc bulge is noted at the L5-S1 level with slight bilateral neural foraminal narrowing.

A fairly large, postero-central and right paracentral extruded disc is noted at the L4-L5 level with thecal sac compression, indentation on the traversing right L5 nerve root and causing right neural foraminal narrowing. A sequestered disc fragment is seen to migrate superiorly in the right lateral recess of L4 indenting the traversing right L4 nerve root.

A small, postero-central protruded disc is noted at the D12-L1 and L3-L4 levels.


Hypertrophic facetal arthropathy and ligamentum flavum prominence at the L4-L5 and L5-S1 levels is noted with facetal hypertrophy in the upper lumbar region.

Type II degenerative marrow changes are noted in the L3 and L4 vertebral bodies superiorly.

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

The conus medullaris terminates at the L1-L2 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 :

16.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
12.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. A fairly large, postero-central and right paracentral extruded disc at the L4-L5 level with indentation on the traversing right L5 nerve root with a sequestered disc fragment seen to migrate superiorly in the right lateral recess of L4 indenting the traversing right L4 nerve root.
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2. A small posterior disc bulge at the L5-S1 level with slight bilateral neural foraminal narrowing.

3. Facetal hypertrophy in the lumbar region with hypertrophic facetal arthropathy and ligamentum flavum prominence at the L4-L5 and L5-S1 levels.

4. Canal stenosis at L4-L5 level and a tight canal at the L5-S1 level.