sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyza Deshlmn / M / 33 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE (left more than right) with paresthesias 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 is loss of normal lumbar lordosis and loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.

A small, postero-central protruded disc with peridiscal osteophyte is noted at the L5-S1 level.

A posteriorly herniated disc with peridiscal osteophyte is noted at the L4-L5 level with thecal sac compression. There is ligamentum flavum hypertrophy at this level with a tight canal.

A fairly large, left paracentral extruded disc is noted at the L3-L4 level with left neural foraminal narrowing and indentation on the traversing left L4 nerve root.

A small posterior peridiscal osteophyte is noted at the L2-L3 level.

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

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

16.0 mm at L1-L2

13.0 mm at L2-L3

8.0 mm at L3-L4

6.0 mm at L4-L5

8.0 mm at L5-S1.

IMPRESSION :

1. A small, postero-central protruded disc with peridiscal osteophyte at the L5-S1 level.

2. A posteriorly herniated disc with peridiscal osteophyte at the L4-L5 level.

3. A fairly large, left paracentral extruded disc at the L3-L4 level with indentation on the traversing left L4 nerve root.

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

5. Canal stenosis at the L3-L4, L4-L5 and L5-S1 levels.