Date : 00.00.00

Name of the Patient : Abc Xyzbai Klmn / F / 57 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE since 2-4 years.

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 lumbar intervertebral discs except the L5-S1 disc.

There is a posterior and a left postero-lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. There is indentation upon the foraminal portion of the left L4 nerve root. The L4-L5 facet joints show mild degenerative changes.

A posterior and a left far lateral disc herniation is seen at the L3-L4 level, with anterior indentation of the thecal sac, left neural foraminal narrowing and indentation upon the extraforaminal and foraminal portion of the left L3 nerve root. The L3-L4 facet joint on the left side shows hypertrophic degenerative changes.







A diffuse posterior disc herniation with bilateral far lateral disc bulges is seen at the L1-L2 and L2-L3 levels with indentation of the thecal sac. There is bilateral neural foraminal narrowing at the L1-L2 level. A sequestered disc fragment is noted along the right, postero-lateral margin of the L1 vertebral body.

A small posterior disc bulge is noted at the D12-L1 level. The lumbar facet joints show degenerative changes.

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

The L3 vertebral body shows evidence of a hemangioma with fat content.

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 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 :

15.0 mm at L1-L2
10.0 mm at L2-L3
11.0 mm at L3-L4
9.0 mm at L4-L5
7.0 mm at L5-S1.

IMPRESSION :

1. A posterior and a left postero-lateral disc herniation at the L4-L5 level with indentation upon the foraminal portion of the left L4 nerve root.
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2. A posterior and a left far lateral disc herniation at the L3-L4 level, with indentation upon the extraforaminal and foraminal portion of the left L3 nerve root. Hypertrophic degenerative changes of the L3-L4 facet joint on the left side is noted.

3. A diffuse posterior disc herniation with bilateral far lateral disc bulges at the L1-L2 and L2-L3 levels. A sequestered disc fragment is noted along the right postero-lateral margin of L1.

4. A small posterior disc bulge at the D12-L1 level.

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