ke/bv/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Dslmn / M / 41 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache and pain in the right gluteal region radiating to the RLE since 6 months.

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 are congenital bony defects in the left pedicles of the L4 and L5 vertebrae. There appears to be congenital defect in the left lamina of the L3 vertebral body also, which appears thin and laterally placed and the left pedicle appears smaller in size.

There are small posterior disc bulges at the L4-L5 and L5-S1 levels with minimal indentation on the S1 nerve roots bilaterally at the L5-S1 level.

A conjoint nerve root is identified on the right side at the L5 level.

Small anterior disc herniations are noted at the L1-L2 and L2-L3 levels.

A meningeal cyst is seen following the course of the left L2 nerve root.



The lumbar intervertebral discs except for the L5-S1 disc shows loss of water content.

There is slight anterior wedging of the L1 and D12 vertebrae without any change in signal intensity.

Type II degenerative changes are noted in the L2, L3 and L4 vertebral bodies anteriorly.

Fat is noted in the filum terminale at the L2 and L3 vertebral levels.

The rest of the lumbar vertebral bodies reveal normal signal intensity. 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 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
15.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. Congenital bony defects in the left pedicles of the L4 and L5 vertebrae and in the left lamina and pedicle of the L3 vertebra.

2. Small posterior disc bulges at the L4-L5 and L5-S1 levels.