sb/bv
Date : 00.00.00

Name of the Patient : Abc Xyz Hemlmn / M / 72 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with radicular pain to BLE with mild paresthesias since 5 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 slight retroplacement of the L3 over the L4 and L4 over the L5 vertebrae.

There is loss of water content of the D10-D11, D12-L1, L3-L4, L4-L5 and L5-S1 intervertebral discs. The L3-L4 and L4-L5 intervertebral discs show evidence of calcium/vacuum phenomena.

A postero-central protruded disc with peridiscal osteophyte is noted at the L5-S1 level. There is facetal and ligamentum flavum hypertrophy and resultant canal stenosis at this level.

There are posteriorly herniated discs with peridiscal osteophytes at the L4-L5 and L3-L4 levels with thecal sac compression and bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy is also noted with canal stenosis. Bilateral far lateral and anterior disc herniations with peridiscal osteophytes are also noted at the L3-L4 and L4-L5 levels. There appears to be impingement of the left L5 nerve root within the neural foramen. This nerve root appears larger in calibre and is probably inflamed.
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Small posterior peridiscal osteophyte is noted at the D12-L1 level and facetal hypertrophy is noted at the D10-D11 level.

The lumbar vertebral bodies adjacent the L3-L4 and L4-L5 intervertebral discs show Type I/III degenerative changes.

The rest of 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 L1 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 :

17.0 mm at L1-L2
16.0 mm at L2-L3
12.0 mm at L3-L4
6.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. A postero-central protruded disc with peridiscal osteophyte at the L5-S1 level with facetal and ligamentum flavum hypertrophy with resultant canal stenosis at this level.

2. Posteriorly herniated discs with peridiscal osteophytes at the L4-L5 and L3-L4 levels with facetal and ligamentum flavum hypertrophy with canal stenosis at this level.