hs/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzChaudlmn / M / 53 yrs.
Referred by : Dr. Abc Xyz / Dr. Abc XyzBR> Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache.

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 mild retroplacement of the L5 vertebra over the S1 vertebra. The visualized dorso-lumbar intervertebral discs show loss of water content.

A small posterior disc herniation is seen to narrow both neural foramina at the L5-S1 level. A left far lateral (extraforaminal) disc herniation is noted at this level.

A small posterior disc herniation with a large peridiscal osteophyte is seen to indent the thecal sac at the D11-D12 level.

There is a posterior disc bulge narrowing both neural foramina at the L4-L5 level. A small right far lateral (extraforaminal) disc herniation is seen at this level.

Small posterior peridiscal osteophytes are noted in the lumbar region.

Facetal hypertrophy is seen at the L3-L4, L4-L5 and L5-S1 levels.


Incidental note is made of a focal hyperintense lesion on all the pulse sequences within the L2 vertebral body and this may represent a hemangioma with high fat content.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining 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 S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

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

IMPRESSION :

The MRI features are suggestive of :

1. A small posterior disc herniation at the L5-S1 level.

2. A small posterior disc herniation with a large peridiscal osteophyte at the D11-D12 level.

3. A posterior disc bulge at the L4-L5 level.

4. Far lateral (extraforaminal) disc herniation on the left side at the L5-S1 level and on the right side at the L4-L5 level.

5. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels.