ke/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Mlmn / F / 25 yrs.
Referred by : Dr. Abc Xyzawat.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE since 8 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 loss of water content of the L4-L5 and L5-S1 intervertebral discs with slight loss of water content of the L1-L2 and L2-L3 intervertebral discs.

There is a posterior disc herniation at the L4-L5 level with posterior peridiscal osteophytes and anterior indentation of the thecal sac. The L4-L5 facet joints show degenerative changes with resultant bilateral neural foraminal narrowing.
Ligamentum flavum hypertrophy is also noted at this level with resultant central and lateral canal stenosis.

A small left paracentral and right far lateral disc herniation is seen at the L5-S1 level with anterior indentation of the thecal sac and mild right neural foraminal narrowing.

Small, posterior disc bulges are noted at the L2-L3 and L3-L4 levels with narrowing of the left neural foramen at the L3-L4 level. Schmorls nodes are seen in the dorso-lumbar vertebrae.

Apparent wedging of the D12 vertebral body with diffuse fatty change is seen and could be due to osteoporosis. Fatty changes are also noted in the lumbar vertebrae.

The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions.

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.

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

A right cortical renal cyst is noted.

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level with facetal arthropathy, ligamentum flavum hypertrophy and resultant central and lateral canal stenosis.

2. A small left paracentral and right far lateral disc herniation at the L5-S1 level.

3. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.