sb/bv/nl/rg.
/3 Date : 00.00.00

Name of the Patient : Abc Xyz Golmn / M / 65 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 10 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.

SOME IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There is minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.

There is loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.

There is a small, posterior and right postero-lateral disc herniation with peridiscal osteophyte at the L5-S1 level, indenting the dural theca anteriorly and slight indentation on the traversing right S1 nerve root. A right far lateral disc herniation is also seen at this level with impingement of the foraminal portion of the right L5 nerve root (scan 102.6).

A postero-central and right paracentral disc herniation is noted at the L4-L5 level with a sequestered disc fragment in the right lateral recess of L5, indenting the traversing right L5 nerve root (scan 104.5). A left far lateral disc herniation with peridiscal osteophyte is also noted at this level.
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Minimal posterior disc bulge is seen at the L3-L4 level.

Facetal hypertrophy is noted at the L1-L2, L4-L5 and L5-S1 levels.

Type II degenerative marrow changes are noted adjacent to the L4-L5 and L5-S1 intervertebral discs.

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 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 :

19.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.

Incidentally noted is a left sided renal cortical cyst.

IMPRESSION :

1. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.

2. A small, posterior and right postero-lateral disc herniation with peridiscal osteophyte at the L5-S1 level, with slight indentation on the traversing right S1 nerve root. A right far lateral disc herniation is also seen at this level with impingement of the foraminal right L5 nerve root
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- 3 - scan-00002


3. A postero-central and right paracentral disc herniation at the L4-L5 level with a sequestered disc fragment in the right lateral recess of L5, indenting the traversing right L5 nerve root.

4. Facetal hypertrophy at the L1-L2, L4-L5 and L5-S1 levels.