ke/sb/rg.
Date : 00.00.00

Name of the Patient : Abc XyzAyub Anlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 4-5 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 :

There is sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.

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

A pseudo-posterior disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is resultant indentation upon the foraminal portion of the left L4 nerve root. Right far lateral disc herniations is also noted at this level. The L4-L5 facet joints show hypertrophic degenerative changes with lateral recess stenosis.

There is a postero-central and bilateral far lateral disc herniations at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is indentation upon the extraforaminal portion of the L3 nerve roots. The L3-L4 facet joints show hypertrophic degenerative changes with resultant lateral recess stenosis.
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- 2 - scan-00007

A right postero-lateral disc herniation is seen at the L2-L3 level with right neural foraminal narrowing.

The lower lumbar intervertebral discs show loss of water content.

Type II degenerative changes are noted in the antero-superior portion of the L5 vertebral body.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and 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 :

15.0 mm at L1-L2
14.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.

2. Slight forward translation of the L4 over the L5 vertebra without obvious spondylolysis.

3. A pseudo-posterior disc herniation at the L4-L5 level with resultant indentation upon the foraminal portion of the left L4 nerve root. Right far lateral disc herniations is also noted at this level with facetal arthropathy and lateral recess stenosis.
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- 3 - scan-00007


4. A postero-central and bilateral far lateral disc herniations at the L3-L4 level with indentation upon the extraforaminal portion of the L3 nerve roots. There is also facetal arthropathy and with resultant lateral recess stenosis.

5. A right postero-lateral disc herniation at the L2-L3 level.

6. Canal stenosis at the L4-L5 and L3-L4 levels.