sb/hs/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyzn Palmn / F / 72 yrs.
Referred by : Dr. Abc Xyzarikh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias since 15 days.

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 minimal forward translation of the L4 vertebra over the L5 vertebra without obvious spondylolysis. There is loss of water content of the lumbar intervertebral discs.

There is a right postero-lateral (foraminal) disc herniation at the L5-S1 level with right neural foraminal narrowing. A left postero-lateral disc bulge is also noted at this level. The facet joints at this level appear slightly hypertrophied.

There is a posteriorly bulging disc at the L4-L5 level with bilateral neural foraminal narrowing. There is severe hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with a resultant severe canal stenosis at this level.

A small posterior disc bulge is noted at the L3-L4 level.

Small left and right (foraminal) disc bulges are noted at the L2-L3 level.


A very small, right paracentral protruded disc is noted at the D12-L1 level.

The dorso-lumbar and the upper lumbar vertebral bodies show spotty fatty marrow changes.

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 :

11.0 mm at L1-L2
10.0 mm at L2-L3
10.0 mm at L3-L4
6.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Minimal forward translation of the L4 vertebra over the L5 vertebra without obvious spondylolysis.

2. A right postero-lateral (foraminal) disc herniation at the L5-S1 level with right neural foraminal narrowing and slight facetal hypertrophy at this level.

3. A posteriorly bulging disc at the L4-L5 level with severe hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with a resultant severe canal stenosis at this level.