ke/hs
Date : 00.00.00

Name of the Patient : Abc Xyza Plmn / F / 35 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE since 10 years.

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.

There is a large left paracentral disc extrusion with peridiscal osteophytes at the L5-S1 level with compression of the thecal sac and canal stenosis. There is indentation upon the traversing left S1 nerve root. Slight ligamentum flavum hypertrophy is noted at the L5-S1 level.

A diffuse posterior disc herniation with peridiscal osteophytes is seen at the L4-L5 level. The L4-L5 facet joint on the left side shows mild degenerative change. Bilateral far lateral (extraforaminal) disc herniations are seen at the L4-L5 level.

Small postero-central disc herniations are noted at the L1-L2 and L2-L3 levels and a posterior disc bulge is seen at the L3-L4 level.

The lumbar intervertebral discs show loss of water content.


Type II degenerative changes are seen within the L5 vertebral body.

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 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 :

17.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
2.0 mm at L5-S1.

IMPRESSION :

1. A large left paracentral disc extrusion at the L5-S1 level with indentation upon the traversing left S1 nerve root and canal stenosis.

2. A diffuse posterior disc herniation at the L4-L5 level with degenerative changes of the L4-L5 facet joint on the left side.

3. Small postero-central disc herniations at the L1-L2 and L2-L3 levels.

4. A posterior disc bulge at the L3-L4 level.

5. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.