ke/sb/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyza Mohd Sullmn / M / 55 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 3 months.

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 forward translation of the L4 over the L5 vertebral body.

A large, diffuse posterior disc herniation is seen at the L4-L5 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. There is indentation upon the foraminal portion of the L4 nerve roots bilaterally. A left far lateral disc herniation is also seen at this level with indentation upon the extraforaminal portion of the left L4 nerve root.

Small posterior disc bulges are seen at the L3-L4 and L5-S1 levels.

Small, postero-central protruded disc with peridiscal osteophytes is noted at the D12-L1 level.

Schmorls nodes are noted in the lumbar region. The lumbar intervertebral discs show loss of water content.


The lower lumbar facet joints show hypertrophic degenerative changes.

There is slight wedging of the L2 vertebral body, without change in signal intensity.

Type II degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.

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 S1 level.

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

14.0 mm at L1-L2
14.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. Slight forward translation of the L4 over the L5 vertebral body.

2. A large, diffuse posterior disc herniation at the L4-L5 level with indentation upon the foraminal portion of the L4 nerve roots bilaterally.
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3. A left far lateral disc herniation at the L4-L5 level indenting the extraforaminal portion of the left L4 nerve root.

4. Hypertrophic facetal arthropathy in the lower lumbar region.

5. Canal stenosis at the L4-L5 level.