ke/sb/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzsa Almn / F / 43 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to the RLE since 1 year.

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 partial sacralization of the L5 vertebra on the left side.

There is a right postero-lateral disc herniation at the L4-L5 level with antero-lateral indentation of the thecal sac and right neural foraminal narrowing. There is superior migration of the disc with impingement of the right L4 nerve root. An intermediate signal intensity lesion on the T1 Weighted images which appears hyperintense on the T2 Weighted images is noted in the right postero-lateral epidural space, compressing the thecal sac. This may either represent a synovial cyst (from the right facet joint), or a sequestered disc fragment. The L4-L5 facet joint on the right side also shows degenerative change with mild ligamentum flavum hypertrophy at the L5 level.

The L1-L2, L2-L3 and L4-L5 intervertebral discs show loss of water content.
Scan-00007


Focal fatty change is noted in the postero-superior aspect of the L2 vertebral body.

The rest of the lumbar vertebral bodies and the remaining intervertebral discs 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 :

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

IMPRESSION :

1. Partial sacralization of the L5 vertebra on the left side.

2. A right postero-lateral disc herniation at the L4-L5 level with superior migration of the disc and impingement of the right L4 nerve root. There is also facetal arthropathy on the right side at this level with a ? synovial cyst, ?? sequestered fragment in the right postero-lateral epidural space at the L4-L5 level.