sb/ke/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzbi Shlmn / F / 48 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE 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 :
There is sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
A posteriorly bulging disc is noted at the L4-L5 level with bilateral neural foraminal narrowing. Hypertrophic facetal arthropathy is noted at this level with lateral recess stenosis and impingement of the left L4 nerve root in the left neural foramen at the L4-L5 level. Facet joint effusion is noted at the L4-L5 level. The L4-L5 intervertebral disc shows loss of water content.
Minimal posterior disc bulges are noted at the L2-L3 and L3-L4 levels.
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-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
17.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
6.0 mm at L5-S1.
IMPRESSION :
1. Sacralized L5 vertebra.
2. A posteriorly bulging disc at the L4-L5 level with bilateral neural foraminal narrowing. Hypertrophic facetal arthropathy is noted at this level with lateral recess stenosis and impingement of the left L4 nerve root in the left neural foramen at the L4-L5 level. Facet joint effusion is noted at the L4-L5 level.