ke/sb
Date : 00.00.00

Name of the Patient : Abc Xyz Phlmn / M / 77 yrs.
Referred by : Dr. Abc Xyzodak.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 3 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 reduction in height of the L4-L5 and L5-S1 intervertebral discs with loss of water content of the lumbar intervertebral discs. Minimal forward translation of L4 over L5 vertebra is noted, without obvious spondylolisthesis.

There is a left postero-lateral and far lateral disc herniation at the L5-S1 level with antero-lateral indentation of the thecal sac and left neural foraminal narrowing. There is indentation upon the foraminal and extraforaminal portion of the left L5 nerve root. The L5-S1 facet joint on the left side shows mild degenerative changes. Anterior disc herniations with anterior and posterior peridiscal osteophytes are also noted at this level.

There is posterior disc herniation with posterior peridiscal osteophyte at the L4-L5 level with anterior indentation of the thecal sac. A right far lateral disc herniation is also noted at this level with indentation upon the extraforaminal portion of the right L4 nerve root. The L4-L5 facet joints show hypertrophic degenerative changes. Ligamentum flavum hypertrophy is seen at the L4-L5 and L5 levels with resultant canal stenosis.
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A disc fragment is seen in the left lateral recess of the L5 vertebra with indentation upon the traversing left L5 nerve root.

Type II degenerative changes are noted in the L5 and S1 vertebrae adjacent to the L5-S1 intervertebral disc.

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 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 :

15.0 mm at L1-L2
17.0 mm at L2-L3
18.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A left postero-lateral and far lateral disc herniation with peridiscal osteophyte at the L5-S1 level with indentation upon the foraminal and extraforaminal portion of the left L5 nerve root.

2. Posterior disc herniation with posterior peridiscal osteophyte at the L4-L5 level with a right far lateral disc herniation at this level with indentation upon the extraforaminal portion of the right L4 nerve root. There is facetal and ligamentum flavum hypertrophy at the L4-L5 and L5 levels with resultant canal stenosis.

3. A disc fragment in the left lateral recess of the L5 vertebra with indentation upon the traversing left L5 nerve root.