sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Dlmn / F / 41 yrs.
Referred by : Dr. Abc Xyzrikh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since 3 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 scoliosis of the lumbar spine with convexity to the left. Mild clockwise rotational anomaly of the upper lumbar vertebrae is noted.

There is sacralization of the L5 vertebra and the D12 vertebral body is as marked on the film.

There is loss of water content of all the lumbar intervertebral discs except the L2-L3 intervertebral disc.

There is a fairly large, postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the anterior dural theca and traversing left L5 nerve root and left neural foraminal narrowing. This disc appears reduced in height.

Minimal posterior disc bulges are noted at the L1-L2 and L2-L3 levels.


Type II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The facet joints and 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 S1 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
18.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Scoliosis of the lumbar spine with convexity to the left.

2. Sacralization of the L5 vertebra and the D12 vertebral body is as marked on the film.

3. A fairly large, postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the traversing left L5 nerve root.