ke/hs/nl.
Date : 00.00.00

Name of the Patient : Abc XyzBlmn / M / 54 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 10 days.

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 mild retroplacement of the L4 vertebra over the L5 vertebra.

A posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. A small portion of the disc is seen to migrate inferiorly and lies posterior to the L5 vertebral body.

A small, postero-central disc herniation is seen to indent the thecal sac at the L5-S1 level. A postero-central disc protrusion is noted at the L1-L2 level.

Bilateral far lateral (extraforaminal) disc bulges are seen at the L4-L5 and L5-S1 levels.

Small posterior disc bulges are seen at the L2-L3 and L3-L4 levels with slight bilateral neural foraminal narrowing at the L3-L4 level.


Schmorls nodes are seen in the lumbar region. The D11-D12, L1-L2, L2-L3 and L4-L5 intervertebral discs show loss of water content.

The L3-L4, L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes. Mild ligamentum flavum hypertrophy is noted over the L4-L5 to the L5-S1 level.

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 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 :

15.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Retroplacement of the L4 vertebra over the L5 vertebra.

2. A posterior disc herniation at the L4-L5 level with a small portion of the disc migrating inferiorly and lying posterior to the L5 vertebral body.

3. A small postero-central disc herniation at the L5-S1 level.
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4. A postero-central disc protrusion at the L1-L2 level.

5. Small posterior disc bulges at the L2-L3 and L3-L4 levels.

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

7. A tight canal at the L4-L5 level.