sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyzlal K. lmn / M / 72 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache since 1 year.
C/O radicular pain to the LLE since 2 days.

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 scoliosis of the lumbar spine with convexity to the left. Clockwise rotational anomaly of the upper lumbar vertebrae is noted.

There is reduction in height of the L3-L4 and L4-L5 discs and loss of water content of the lumbar intervertebral discs.

There is slight anterior translation of the L3 over the L4 vertebra and slight retroplacement of the L4 over the L5 vertebra.

Left postero-lateral and left far lateral disc bulge with peridiscal osteophyte is noted at the L5-S1 level with slight left neural foraminal narrowing. Facetal hypertrophy is noted at this level.





A left postero-lateral disc herniation with peridiscal osteophyte is seen at the L4-L5 level indenting the traversing left L5 nerve root and narrowing the left neural foramen at that level. Facetal and ligamentum flavum hypertrophy is noted at this level.

A right postero-lateral disc bulge with peridiscal osteophyte is noted at the L3-L4 level with right neural foraminal narrowing. Right sided facetal and ligamentum flavum hypertrophy is noted at this level.

Type III degenerative marrow changes are noted adjacent to the L3-L4 disc.

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 L2 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 :

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

The cerivco-dorsal spine was screened with the help of 5 mm thick T1 Weighted sagittal images which do not reveal any diagnostic feature of note.

IMPRESSION :

1. Scoliosis of the lumbar spine with convexity to the left with clockwise rotational anomaly of the upper lumbar vertebrae.
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2. Slight anterior translation of the L3 over the L4 vertebra and slight retroplacement of the L4 over the L5 vertebra.

3. Left postero-lateral and left far lateral disc bulge with peridiscal osteophyte at the L5-S1 level with facetal hypertrophy at this level.

4. A left postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level indenting the traversing left L5 nerve root with facetal and ligamentum flavum hypertrophy at this level.

5. A right postero-lateral disc bulge with peridiscal osteophyte at the L3-L4 level with right sided facetal and ligamentum flavum hypertrophy at this level.