sb/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz. Vallmn / M / 58 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE since 00.00.00.

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 slight loss of water content of the lumbar intervertebral discs.

A small posterior disc herniation is noted at the L4-L5 level with bilateral neural foraminal narrowing. A small right far lateral (extraforaminal) disc herniation is seen at the L4-L5 level with indentation upon the extraforaminal portion of the exiting right L4 nerve root.

Small left and right postero-lateral disc herniations are noted at the L3-L4 level, with slight bilateral neural foraminal narrowing.

Facetal hypertrophy is noted at the L2-L3, L3-L4 and L4-L5 levels.

Far lateral (extraforaminal) disc bulges are noted bilaterally at the L1-L2, L2-L3 and L3-L4 levels and on the left side at the L4-L5 level.


Mild ligamentum flavum hypertrophy is seen at the L4-L5 and L5 levels.

Type II degenerative marrow changes are noted in the L1 vertebral body adjacent to the L1-L2 intervertebral disc.

The pedicles of the lumbar vertebrae appear to be congenitally short in their antero-posterior dimensions.

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 D12-L1 level and the thecal sac terminates at the L5 level.

Fat is noted in the filum terminale over the L2 to L5 vertebral levels.

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

18.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. A small posterior disc herniation at the L4-L5 level with bilateral neural foraminal narrowing.

2. Small left and right postero-lateral disc herniations at the L3-L4 level, with slight bilateral neural foraminal narrowing.

3. Facetal hypertrophy at the L2-L3, L3-L4 and L4-L5 levels.
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4. A small right far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting right L4 nerve root at the L4-L5 level.

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

6. Mild ligamentum flavum hypertrophy at the L4-L5 and L5 levels.