hs/sb/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzc Calmn / M / 38 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radiation of pain to the LLE 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 :

The L5 vertebra appears to be sacralized and it is as marked on the film.

The lumbar intervertebral discs show loss of water content.

A large posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L3-L4 level. Large right postero-lateral and right far lateral disc herniations are seen to indent the exiting right L4 nerve root at this level. A left far lateral (extraforaminal) disc herniation is also noted at this level. A sequestered disc fragment is noted in the right lateral and posterior epidural space at L3 and L4 vertebral levels.

A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. Bilateral far lateral (extraforaminal) disc bulges are noted at this level.

Right postero-lateral and right far lateral disc herniations are seen at the L2-L3 level.
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The L2-L3, L3-L4 and L4-L5 facet joints show degenerative changes. Posterior peridiscal osteophytes are noted in the lumbar region.

A posteriorly bulging disc with peridiscal osteophytes is seen at the D12-L1 level.

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

The lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1-L2 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 :

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

IMPRESSION :

The MRI features are suggestive of :

1. A large posterior disc herniation with canal stenosis at the L3-L4 level. A sequestered disc fragment is noted in the right lateral and posterior epidural space at L3 and L4 vertebral levels.

2. A posterior disc herniation at the L4-L5 level.

3. Large right postero-lateral and right far lateral disc herniations at the L3-L4 level.
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4. Facetal arthropathy at the L2-L3, L3-L4 and L4-L5 levels.

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

6. Sacralization of the L5 vertebra.