sb/bv
Date : 00.00.00

Name of the Patient : Abc Xyze lmn / M / 25 yrs.
Referred by : Dr. Abc Xyzni / Dr. Abc Xyzhijwala.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 1 month.

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 L3-L4 and L5-S1 intervertebral discs.

There is a postero-central disc herniation with peridiscal osteophyte at the L5-S1 level, slightly more to the left of the midline. Slight inferior migration of the disc fragment is noted with indentation on the dural theca anteriorly.

Posteriorly bulging discs are noted at the L4-L5 and L3-L4 levels.

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

Schmorls nodes are noted in the lumbar region.

A limbus vertebra is seen at the L4 vertebral level.


There is loss of normal posterior epidural fat of the D12 and upper half of the L1 vertebral levels. The thecal sac is widened at that level. The CSF posterior to the intrathecal nerve roots at these levels is slightly more hyperintense on the T2 Weighted images. The D12 nerve root sleeves appear baggy bilaterally, more on the left side. The intrathecal nerve roots at the D12 and L1 vertebral levels seem to be placed slightly more anteriorly than normal.

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

The conus medullaris terminates at the D12 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 :

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

IMPRESSION :

1. A postero-central disc herniation with peridiscal osteophyte at the L5-S1 level, slightly more to the left of the midline with slight inferior migration of the disc fragment.

2. Posteriorly bulging discs at the L4-L5 and L3-L4 levels.

3. Changes in the dural sac identified at the D12 and L1 vertebral levels may suggest dural ectasia. An intradural arachnoid cyst cannot be, however, excluded.