ke/sb
Date : 00.00.00

Name of the Patient : Abc Xyzah lmn / M / 38 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE with paresthesias since 3 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 a posterior and a right postero-lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and the traversing right L5 nerve root. A sequestered disc fragment is seen to lie in the left lateral recess of the L5 vertebra with indentation on the traversing left L5 nerve root. Posterior peridiscal osteophytes are also noted at this level.

Posterior disc bulges are seen at the L2-L3 and L3-L4 levels with right far lateral disc bulge at the L3-L4 level.

Schmorls nodes are seen in the dorso-lumbar region. The L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content.











The L2-L3 and L4-L5 facet joints bilaterally and the L3-L4 facet joint on the right side show degenerative changes.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and 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 :

17.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
16.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

1. A posterior and a right postero-lateral disc herniation with posterior peridiscal osteophytes at the L4-L5 level indenting the traversing right L5 nerve root. A sequestered disc is seen to lie in the left lateral recess of the L5 vertebra with indentation on the traversing left L5 nerve root.

2. Posterior disc bulges at the L2-L3 and L3-L4 levels with a right far lateral disc bulge at the L3-L4 level.

3. Degenerative changes of the L2-L3 and L4-L5 facet joints bilaterally and the L3-L4 facet joint on the right side.