Date : 00.00.00

Name of the Patient : Abc Xyzam D. Gailmn / M / 40 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias 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 evidence of a large postero-central disc extrusion compressing the thecal sac at the L4-L5 level. A disc portion is seen to lie within the anterior epidural space at the L5 vertebral level.

A postero-central disc herniation is seen to indent the thecal sac at the L3-L4 level. Also seen a postero-central disc herniation with peridiscal osteophytes indenting the thecal sac at the L1-L2 level.

There are posterior disc bulges at the L2-L3 and L5-S1 levels.

The L2-L3, L3-L4, L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes.

The lumbar intervertebral discs show loss of water content.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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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 :

11.0 mm at L1-L2
12.0 mm at L2-L3
9.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A large postero-central disc extrusion at the L4-L5 level with severe canal stenosis. A disc portion is seen to lie within the anterior epidural space at the L5 vertebral level.

2. A postero-central disc herniation at the L3-L4 level with a tight canal.

3. A postero-central disc herniation with peridiscal osteophytes at the L1-L2 level.

4. Hypertrophic facetal arthropathy at the L2-L3, L3-L4, L4-L5 and L5-S1 levels.