Date : 00.00.00

Name of the Patient : Abc Xyz G. lmn / M / 55 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 5-6 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 sacralization of the L5 vertebra and the L1 vertebral body is marked on the film.

There is reduction in height of the L3-L4 intervertebral disc with loss of water content of the lumbar intervertebral discs.

A posteriorly bulging disc with posterior peridiscal osteophytes is noted at the L4-L5 level with bilateral neural foraminal narrowing. There is also facetal and ligamentum flavum hypertrophy with resultant lateral recess and central canal stenosis.

A posterior and right far lateral peridiscal osteophyte is noted at the L3-L4 level with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L3 nerve root. Facetal and ligamentum flavum hypertrophy with canal stenosis is also noted.
00007 - 2 -


A postero-central disc herniation is noted at the L2-L3 level with thecal sac compression. Facetal hypertrophy is also noted at this level.

Anterior disc herniations with anterior peridiscal osteophytes are noted in the lumbar region.

Type II degenerative changes are noted adjacent to the L3-L4 disc.

The rest of the lumbar vertebral bodies 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

11.0 mm at L2-L3

12.0 mm at L3-L4

7.0 mm at L4-L5

8.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A posteriorly bulging disc with posterior peridiscal osteophyte at the L4-L5 level with facetal and ligamentum flavum hypertrophy.
..3/.






00007
- 3 -


3. A posterior and right far lateral peridiscal osteophyte at the L3-L4 level with right neural foraminal narrowing and indentation on the extraforaminal segment of the right L3 nerve root. Facetal and ligamentum flavum hypertrophy is also noted.

4. A postero-central disc herniation at the L2-L3 level with facetal hypertrophy at this level.

5. Lumbar canal stenosis over L2-L3 to L4-l5 levels.