hs/sb
Date : 00.00.00

Name of the Patient : Abc Xyzli Sakalmn / M / 58 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias since 15 days.
H/O being hit by a heavy object.

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 :

The L5 vertebra appears as marked on the film. Please correlate with plain radiographs.

A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. A right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L4 nerve root. The L4-L5 facet joints show mild hypertrophic degenerative changes. Also seen is mild ligamentum flavum hypertrophy at this level.

A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L3-L4 level. A small posterior disc bulge is noted at the L2-L3 level. A small left postero-lateral (foraminal) disc herniation is seen to narrow the left neural foramen at the L2-L3 level. A probable small disc fragment is noted in the left lateral recess of the L3 vertebra (se/im 104/15).


There are far lateral (extraforaminal) disc bulges bilaterally at the L2-L3 and L3-L4 levels and on the left side at the L4-L5 level.

The rest of the lumbar facet joints show mild degenerative changes. The pedicles of the lower lumbar vertebrae appear to be congenitally short in their antero-posterior dimensions.

The D11-D12, L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content. The urinary bladder is markedly distended. Anterior disc herniations are noted at the L2-L3, L3-L4 and L4-L5 levels.

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

The conus medullaris terminates at the D12 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
15.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

1. A posterior disc herniation, mild hypertrophic facetal arthropathy and mild ligamentum flavum hypertrophy with resultant canal stenosis at the L4-L5 level.
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2. A small posterior disc herniation at the L3-L4 level.

3. A right far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting right L4 nerve root at the L4-L5 level.

4. Mild facetal arthropathy in the lumbar region.

5. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions.