ke/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzlal lmn / M / 78 yrs.
Referred by : Dr. Abc Xyzmpat / Dr. Abc Xyzhatt.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 1 month.

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 straightening of the lumbar spine with slight forward translation of the L2 over the L3 vertebral body.

A posterior and bilateral postero-lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. A left far lateral disc herniation is also seen at this level with indentation upon the extraforaminal portion of the left L3 nerve root.

A diffuse posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.

The fat within the neural foramen on the right side at the L4 level is obliterated and there is a suggestion of the right L4 nerve root being inflamed.

Small posterior disc bulge is seen at the L5-S1 level with mild indentation upon the right S1 nerve root.


There is diffuse posterior disc herniation at the L2-L3 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.

Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.

The L1-L2, L2-L3, L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes bilaterally. The L5-S1 facet joint on the right side shows mild degenerative change.

The lumbar intervertebral discs show loss of water content.

Type II degenerative changes are noted in the lumbar vertebrae.

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
10.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.

Incidental note is made of cortical renal cyst on the right side.
..3/.











- 3 - Scan-00008


IMPRESSION :

1. Forward translation of the L2 over the L3 vertebral body.

2. A posterior and bilateral postero-lateral disc herniation at the L3-L4 level with bilateral neural foraminal narrowing.

3. A left far lateral disc herniation at the L3-L4 level with indentation upon the extraforaminal portion of the left L3 nerve root.

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

5. Diffuse posterior disc herniation at the L2-L3 level.

6. Small posterior disc bulge at the L5-S1 level with mild indentation upon the right S1 nerve root.

7. Inflammation of the right L4 nerve root.

8. Hypertrophic facetal arthropathy at the L1-L2, L2-L3, L3-L4 and L4-L5 levels bilaterally and mild facetal arthropathy on the right side at the L5-S1 level.

9. Canal stenosis at the L2-L3, L3-L4 and L4-L5 levels.