ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Abdul Rlmn / M / 38 yrs.
Referred by : Dr. Abc Xyz Kothawala.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE 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 loss of water content of the L4-L5 disc.

There is a left postero-lateral disc extrusion at the L4-L5 level with antero-lateral indentation of the thecal sac with left neural foraminal narrowing. There is rupture of the posterior longitudinal ligament. There is inferior migration of the disc which is seen to lie in the left lateral recess of the L5 vertebral body with compression of the thecal sac and impingement of the traversing left L5 nerve root. Mild ligamentum flavum hypertrophy is also noted at this level.

The L3-L4 and L4-L5 facet joints on the right side show degenerative changes.

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.
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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
10.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A left postero-lateral disc extrusion at the L4-L5 level with inferior migration of the disc which is seen
to lie in the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root with mild ligamentum flavum hypertrophy.

2. Facetal arthropathy at the L3-L4 and L4-L5 levels on the right side.