sb/ke/rg.
Date : 00.00.00

Name of the Patient : Abc Xyz Mlmn / M / 67 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE since 3 years.

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 scoliosis of the lumbar spine with convexity to the right.

There is reduction in height of all the lumbar intervertebral discs except the L5-S1 disc and loss of water content of all the lumbar intervertebral discs.

Slight retroplacement of the L4 over L5 and L3 over L4 vertebrae is noted.

Posterior peridiscal osteophytes are noted at all the lumbar intervertebral disc levels. There is a right postero-lateral and far lateral disc herniation at the L4-L5 level with right neural narrowing and impingement of the right L4 nerve root in the right neural foramen at the L4-L5 level. There is also ligamentum flavum and facetal hypertrophy at the L4-L5 level with a tight canal.

Bilateral neural foraminal narrowing is noted at the L3-L4 level.


Type II degenerative marrow changes are noted in the lumbar vertebral bodies adjacent to all the intervertebral discs except the L5-S1 disc.

The rest of the 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 :

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

IMPRESSION :

1. Scoliosis of the lumbar spine with convexity to the right.

2. Slight retroplacement of the L4 over L5 and L3 over L4 vertebrae.

3. Posterior peridiscal osteophytes at all the lumbar intervertebral disc levels.

4. A right postero-lateral and far lateral disc herniation at the L4-L5 level with impingement of the right L4 nerve root in the right neural foramen at the L4-L5 level. There is also ligamentum flavum and facetal hypertrophy at the L4-L5 level with a tight canal.