sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyza S. Shlmn / F / 55 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with numbness since 2 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 water content of the L2-L3 to the L5-S1 intervertebral discs. slight reduction in height of the L5-S1 intervertebral disc is noted.

There is a posteriorly herniated disc with posterior peridiscal osteophyte at the L5-S1 level with bilateral neural foraminal narrowing.

A posteriorly herniated disc with peridiscal osteophyte is noted at the L4-L5 level with thecal sac compression. A sequestered disc fragment is noted in the anterior epidural space along the posterior margin of the L5 vertebra, to the left of the midline, indenting the traversing left L5 nerve root. Slight facetal and ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels with a tight lumbar canal at that level.





A posterior and right postero-lateral disc bulge is noted at the L3-L4 level, with bilateral neural foraminal narrowing, right more than left.

Small posterior disc bulge is seen at the L2-L3 level. There are Schmorls nodes in the lumbar region.

Type II degenerative marrow changes are noted adjacent to the L5-S1 disc and superior aspect of the L4 vertebra.

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

The conus medullaris terminates at the L1-L2 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 :

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

IMPRESSION :

1. A posteriorly herniated disc with posterior peridiscal osteophyte at the L5-S1 level with bilateral neural foraminal narrowing.

2. A posteriorly herniated disc with peridiscal osteophyte at the L4-L5 level with a sequestered disc fragment in the anterior epidural space along the posterior margin of the L5 vertebra, to the left of the midline, indenting the traversing left L5 nerve root.
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3. Slight facetal and ligamentum flavum hypertrophy at the L4-L5 and L5 levels with a tight lumbar canal at that level.

4. A posterior and right postero-lateral disc bulge at the L3-L4 level, with bilateral neural foraminal narrowing, right more than left.