ke/sb/rg.
Date : 00.00.00

Name of the Patient : Abc Xyza lmn / F / 66 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in the RLE since 6-8 months.

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 a posterior disc bulge with posterior peridiscal osteophytes at the L4-L5 level with anterior indentation of the thecal sac. Bilateral far lateral disc bulges are also noted at this level with indentation upon the extraforaminal portion of the L4 nerve roots.

Small posterior disc bulges are noted at the L1-L2 level, L2-L3, L3-L4 and L5-S1 levels with posterior peridiscal osteophytes. The right L5 nerve root is impinged in the right neural foramen at the L5-S1 level. The lumbar intervertebral discs show loss of water content. Calcium/vacuum phenomena is noted in the L2-L3, L3-L4 and L4-L5 discs.

The lumbar facet joints show degenerative changes.

Type III degenerative changes are noted in the L4 and L5 vertebrae adjacent to the L4-L5 intervertebral disc.
- 2 - scan-00004


The rest of the 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 L5-S1 level.

There is slight increase in the epidural fat at the L5 and S1 vertebral levels with a trifoliate thecal sac at the L5-S1 level, suggesting epidural lipomatosis (scans 105.3-5).

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

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

IMPRESSION :

1. A posterior disc bulge with posterior peridiscal osteophytes at the L4-L5 level. Bilateral far lateral disc bulges are also seen at this level with indentation upon the extraforaminal portion of the L4 nerve roots.

2. Small posterior disc bulges with posterior peridiscal osteophytes at the L1-L2 level, L2-L3, L3-L4 and L5-S1 levels with impingement of the right L5 nerve root in the right neural faramen at the L5-S1 level.

3. Facetal arthropathy in the lumbar region.

4. Tight canal at the L2-L3, L3-L4 and L4-L5 levels.

5. Epidural lipomatosis at the L5 and S1 vertebral levels.