ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Glmn / F / 40 yrs.
Referred by : Dr. Abc Xyznwal Pannu.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 1 year.

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 L4-L5 intervertebral disc shows loss of water content.

A large posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina with impingement of both the exiting L4 nerve roots at the L4-L5 level. Bilateral foraminal and extraforaminal disc herniations are noted at this level.

There is a postero-central disc protrusion at the L5-S1 level.

The L3-L4, L4-L5 and L5-S1 facet joints show degenerative changes.

Bilateral far lateral (extraforaminal) disc bulges are noted at the L2-L3 and L3-L4 levels.

There is an anterior disc herniation at the L4-L5 level.
- 2 - Scan-00007


Type I (hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images) degenerative changes are seen within the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc. Type II (isointense to fat) degenerative changes are seen in the antero-superior aspect of the L3 vertebral body.

The lumbar intervertebral discs show loss of water content.

The rest of the lumbar vertebral bodies 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 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 :

14.0 mm at L1-L2
14.0 mm at L2-L3
16.0 mm at L3-L4
16.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A large posterior disc herniation with peridiscal osteophytes causing canal stenosis at the L4-L5 level with foraminal and extraforaminal disc herniations at this level.

3. Facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels.