sb/ke
Date : 00.00.00

Name of the Patient : Abc Xyz G. Slmn / M / 65 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache 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 normal lumbar lordosis and loss of water content of the lumbar intervertebral discs.

Posteriorly herniated discs with posterior peridiscal osteophytes are noted at the L2-L3, L3-L4, L4-L5 and L5-S1 levels with bilateral neural foraminal narrowing. Bilateral far lateral disc bulges are also noted at these levels. There is indentation on the traversing L5 and S1 nerve roots at the L4-L5 and L5-S1 levels, respectively. Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.

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

Anterior disc herniations with anterior peridiscal osteophytes are noted in the lumbar region.

Hemangiomas with fat content are noted in the L3 and L1 vertebral bodies and Type II degenerative changes in the L5 and S1 vertebrae adjacent to the L5-S1 intervertebral disc is also noted.


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 :

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

IMPRESSION :

1. Posteriorly herniated discs with posterior peridiscal osteophytes and bilateral far lateral disc bulges at the L2-L3, L3-L4, L4-L5 and L5-S1 levels with bilateral neural foraminal narrowing. Indentation on the traversing L5 and S1 nerve roots is noted at the L4-L5 and L5-S1 levels, respectively.

2. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels.

3. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions, with lumbar canal stenosis.