sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzriben lmn / F / 76 yrs.
Referred by : Dr. Abc Xyzrman.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE, paresthesias and difficulty in walking.
Alleged H/O fall 1 month ago.

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 loss of water content of the lumbar intervertebral discs.

There is a small left postero-lateral disc bulge at the L5-S1 level with slight left neural foraminal narrowing.

Posterior and bilateral far lateral disc herniations are noted at the L3-L4 and L4-L5 levels with thecal sac compression and bilateral neural foraminal narrowing. Indentation on the traversing L4 and L5 nerve roots respectively is noted at these levels.

A fairly large, postero-central and left paracentral disc herniation is noted at the L2-L3 level with indentation on the traversing left L3 nerve root. Slight superior migration of the disc fragment is noted. Bilateral far lateral (extraforaminal) disc herniations are seen at the L2-L3 level and on the right side at the L1-L2 level.



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

Facetal hypertrophy is noted in the dorso-lumbar and lumbar regions bilaterally.

The visualized dorso-lumbar vertebral bodies show spotty fatty marrow changes. 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 :

13.0 mm at L1-L2
13.0 mm at L2-L3
9.0 mm at L3-L4
6.0 mm at L4-L5
8.0 mm at L5-S1.

Screening T2 Weighted sagittal images of the dorsal spine do not reveal any other significant feature of note.

IMPRESSION :

1. A small left postero-lateral disc bulge at the L5-S1 level with slight left neural foraminal narrowing.

2. Posterior and bilateral far lateral disc herniations at the L3-L4 and L4-L5 levels with bilateral neural foraminal narrowing and indentation on the traversing L4 and L5 nerve roots respectively at these levels.
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3. A fairly large, postero-central and left paracentral disc herniation at the L2-L3 level with indentation on the traversing left L3 nerve root. Slight superior migration of the disc fragment is noted.

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

5. Facetal hypertrophy in the dorso-lumbar and lumbar regions bilaterally.

6. Lumbar canal stenosis, maximum at the L2-L3, L3-L4 and L4-L5 levels.

7. Far lateral (extraforaminal) disc herniations bilaterally at the L2-l3 level and on the right side at the L1-L2 level.