ke/bv/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzi Khalmn / F / 58 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias since 15-20 days.
Alleged H/O vehicular accident 4 years back with fracture of the left hip region.

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.

FEW IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There is sacralization of the L5 vertebral body and the L3 vertebral body is as marked on the film.

There is a left paracentral disc herniation at the L4-L5 level with antero-lateral indentation of the thecal sac and left neural foraminal narrowing. Slight inferior migration of the disc is noted posterior to the L5 vertebral body in the left lateral recess with impingement of the traversing left L5 nerve root. A small left far lateral disc bulge is also noted at the L4-L5 level with indentation upon the extraforaminal portion of the left L4 nerve root. The L4-L5 facet joints show degenerative changes (scans 104.5, 104.6, 104.7).



Small posterior disc herniations are seen at the L1-L2, L2-L3 and L3-L4 levels with anterior indentation of the thecal sac. The lumbar intervertebral discs show loss of water content.

The lumbar vertebral bodies show diffuse fatty changes. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 level and the thecal sac terminates at the L5 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
16.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A left paracentral disc herniation at the L4-L5 level with impingement of the traversing left L5 nerve root.

3. A small left far lateral disc bulge at the L4-L5 level with indentation upon the extraforaminal portion of the left L4 nerve root.

4. L4-L5 facetal arthropathy.