sb/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Dhargalmn / M / 48 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 1 1/2 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 sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
There is loss of water content of the L1-L2 and L4-L5 interverebral discs.
There is minimal forward translation of the L4 vertebra over the L5 vertebra without obvious spondylolysis.
A small posterior disc herniation is noted at the L4-L5 level. There is also hypertrophic facetal arthropathy and resultant lateral recess stenosis at this level. There is bilateral neural foraminal narrowing at the L4-L5 level with impingement of the exiting left L4 nerve root. Bilateral far lateral (extraforaminal) disc herniations are noted at this level.
Right far lateral (extraforaminal) disc bulges are noted at the L2-L3 and L3-L4 levels.
There is slight anterior wedging of the L1 vertebral body without change in signal intensity. A hemangioma with fat content (hyperintense on all the pulse sequences) is noted in the D12 vertebral body.
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 D12-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 :
19.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.
IMPRESSION :
1. Sacralization of the L5 vertebra.
2. Minimal forward translation of the L4 vertebra over the L5 vertebra without obvious spondylolysis.
3. A small posterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy and resultant lateral recess stenosis.
4. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.