hs/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzShirolmn / M / 53 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to the RLE since 2 weeks.

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 :

The L5 vertebra appears to be as marked on the film. Please correlate with plain radiographs. There is mild forward listhesis of the L4 vertebra over the L5 vertebra.

A right postero-lateral disc herniation with peridiscal osteophytes is seen to narrow the right neural foramen at the L4-L5 level. A sequestered disc fragment is seen to lie within the right lateral recess of the L4 vertebra with indentation upon the thecal sac. A small postero-central disc herniation is seen at the L4-L5 level.

Postero-central and right postero-lateral disc herniations with peridiscal osteophytes are seen to indent the thecal sac and narrow the right neural foramen, respectively at the L5-S1 level.

Far lateral (extraforaminal) disc herniations are seen bilaterally at the L4-L5 and L5-S1 levels and on the right side at the L2-L3 level. A small right postero-lateral disc herniation is seen to narrow the right neural foramen at the L2-L3 level.


The L4-L5 facet joints show hypertrophic degenerative changes.

The L2-L3 to the L5-S1 intervertebral discs show loss of water content.

The lumbar vertebral bodies and the L1-L2 intervertebral disc 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 S2 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
16.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
14.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A right postero-lateral disc herniation and a small postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with a sequestered disc fragment lying within the right lateral recess of the L4 vertebra.

2. Hypertrophic facetal arthropathy at the L4-L5 level.
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3. Postero-central and right postero-lateral disc herniation with peridiscal osteophytes at the L5-S1 level.

4. A small right postero-lateral disc herniation at the L2-L3 level.

5. Far lateral (extraforaminal) disc herniations bilaterally at the L4-L5 and L5-S1 levels and on the right side at the L2-L3 level.