hs/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Mhlmn / F / 62 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with paresthesias 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 mild forward translation of the L3 vertebra over the L4 vertebra and mild retroplacement of the L2 vertebra over the L3 vertebra.

A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. A disc portion is seen to lie within the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root.

Postero-lateral (foraminal) disc herniations are seen to narrow the neural foramina bilaterally at the L2-L3 and L3-L4 levels.

There is a posterior disc bulge at the L5-S1 level. Bilateral far lateral (extraforaminal) disc bulges are noted over the L2-L3 to L5-S1 levels.

The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes. Facetal hypertrophy is seen at the L5-S1 level.


There is mild ligamentum flavum hypertrophy at the L4-L5, L5 and L5-S1 levels.

The pedicles of the lumbar vertebrae appear to be congenitally short in their antero-posterior dimensions.

A Schmorls node is seen at the inferior aspect of the L2 vertebral body.

The lumbar intervertebral discs show loss of water content. Anterior disc herniations with peridiscal osteophytes are seen at the L2-L3, L3-L4 and L4-L5 levels.

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 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
12.0 mm at L2-L3
9.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.

The cervico-dorsal spine was screened with 5 mm thick T1 Weighted sagittal images and the C5 and C6 vertebral bodies show areas of hypointensity. If clinically indicated a dedicated study of the cervical spine may be performed.
..3/.












- 3 - Scan-00007

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation at the L4-L5 level with a disc portion seen to lie within the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root.

2. Postero-lateral (foraminal) disc herniations
at the L2-L3 and L3-L4 levels.

3. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels and facetal hypertrophy at the L5-S1 level.

4. Mild ligamentum flavum hypertrophy at the L4-L5, L5 and L5-S1 levels.

5. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.

6. Canal stenosis at the L3-L4 and L4-L5 levels and a tight canal at the L2-L3 level.