sb/bv/rg.
Date : 00.00.00

Name of the Patient : Abc XyzBegum Halmn / F / 76 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O low backpain radiating to BLE (right more than left) with paresthesias.

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 anterior wedging of the L3 vertebral body.

There is loss of water content of the lumbar intervertebral discs. The L3-L4 intervertebral discs show evidence of calcium/vacuum phenomena.

There is minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.

There is a postero-central and left postero-lateral disc herniation at the L5-S1 level with left neural foraminal narrowing and impingement of the left L5 nerve root in the left neural foramen at the L5-S1 level. There is also facetal and ligamentum flavum hypertrophy at that level (scan 102.2).





There is a small posterior disc bulge with a right postero-lateral (foraminal) disc herniation at the L4-L5 level narrowing the right neural foramen at that level. Hypertrophic facetal arthropathy is noted at this level. There is slight retroplacement of the L3 over the L4 vertebra. Posterior peridiscal osteophytes/new bone formation is noted to the right of the midline at the L3-L4 level with thecal sac compression and impingement of the
right L3 nerve root in the right lateral recess at the L3-L4 level. A posterior and right postero-lateral disc herniation is also noted at this level with bilateral neural foraminal narrowing. Facetal hypertrophy is also noted at this level.

Small posterior disc bulges with posterior peridiscal osteophytes are noted at the L1-L2 and L2-L3 levels.

The L3 vertebral body is wedged anteriorly. Ill-defined, hyperintense signal on T2 Weighted images is noted in the L3 and L4 vertebral bodies adjacent to the L3-L4 disc. This lesion appears hypointense on the T1 Weighted images and most likely represents Type I degenerative changes (marrow edema). Type II degenerative marrow changes are noted adjacent to the L5-S1 intervertebral disc.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The rest of the 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 S1 level.

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

10.0 mm at L1-L2
12.0 mm at L2-L3
..3/.






- 3 - Scan-00005



14.0 mm at L3-L4
15.0 mm at L4-L5
15.0 mm at L5-S1.

IMPRESSION :

Degenerative disease of the lumbar spine with :

1. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.

2. A postero-central and left postero-lateral disc herniation at the L5-S1 level with left neural foraminal narrowing and impingement of the left L5 nerve root in the left neural foramen at the L5-S1 level.

3. A small posterior disc bulge with a right postero-lateral (foraminal) disc herniation at the L4-L5 level, narrowing the right neural foramen at that level.

4. Slight retroplacement of the L3 over the L4 vertebra with posterior peridiscal osteophytes/new bone formation to the right of the midline at the L3-L4 level with impingment of the right L3 nerve root in the right lateral recess at the L3-L4 level.

5. Facetal and ligamentum flavum hypertrophy at the L3-L4, L4-L5 and L5-S1 levels with canal stenosis at these levels.