ke/bv
Date : 00.00.00

Name of the Patient : Abc XyzR. Talmn / F / 60 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O bacache radiating to the LLE with paresthesias 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 suggestion of the sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.

There is forward subluxation of the L4 over the L5 vertebra with a pseudo-posterior disc herniation at the L4-L5 level. There is anterior indentation of the thecal sac and bilateral neural foraminal narrowing at this level. The L4-L5 facet joints show hypertrophic degenerative changes bilaterally, left more than right. There is indentation upon the foraminal portion of the left L4 nerve root with canal stenosis.

A left postero-lateral disc herniation is seen at the L5-S1 level with mild indentation upon the left S1 nerve root. The L5-S1 facet joints show slight degenerative change.

A small, left paracentral and far lateral disc herniation is seen at the L3-L4 level.


The lumbar intervertebral discs show loss of water content.

Focal fatty changes are noted in the upper lumbar vertebrae.

A large Schmorls node is seen in the superior aspect of the D11 vertebra.

The L1-L2, L2-L3 and L3-L4 facet joints show degenerative changes.

Anterior peridiscal osteophytes are seen in the lumbar region.

The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12-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 :

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

IMPRESSION :

1. Sacralization of the L5 vertebra.
2. Forward subluxation of the L4 over the L5 vertebra.
3. A pseudo-posterior disc herniation at the L4-L5 level with
indentation upon the foraminal portion of the left L4 nerve root and hypertrophic facetal arthropathy at this level.
4. A left postero-lateral disc herniation at the L5-S1 level with mild indentation upon the left S1 nerve root and slight facetal arthropathy at this level.
5. Facetal arthropathy at the L1-L2, L2-L3 and L3-L4 levels.
6. A small, left paracentral and far lateral disc herniation at the L3-L4 level.