sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz. Palmn / M / 27 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE with paresthesias.

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 normal lumbar lordosis and loss of water content of the D11-D12, D12-L1, L1-L2 and L4-L5 intervertebral discs.

There is a postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with thecal sac compression.

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

Small posterior disc bulges are noted at the L5-S1, L3-L4 and L1-L2 levels with small posterior peridiscal osteophytes at the L1-L2 level.

There is an increase in the posterior epidural fat in the upper lumbar region.

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

The intrathecal nerve roots appear to be clumped, centrally due to an increase in the posterior epidural fat and hence compromise of the lumbar canal.
..2/.






The articular facets in the lumbar region appear slightly hypertrophied.

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

The conus medullaris terminates at the D12 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 :

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

IMPRESSION :

1. A postero-central disc herniation with peridiscal osteophytes at the L4-L5 level.

2. Small posterior disc bulges at the L5-S1, L3-L4 and L1-L2 levels with small posterior peridiscal osteophytes at the L1-L2 level.

3. Slight increase in the posterior epidural fat in the upper lumbar region may suggests epidural lipomatosis.

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

5. Slight facetal hypertrophy in the lumbar region.

6. Tight lumbar canal, maximum at L4-L5 level.