sb/hs/rg/nl
Name of the Patient : Abc Xyzlya lmn / F / 65 yrs.
Referred by : Dr. Abc Xyzrawal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias.
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 water content of all the lumbar intervertebral discs except the D12-L1 and L1-L2 discs.
There is a small, postero-central disc herniation at the L5-S1 level, indenting the traversing S1 nerve roots bilaterally. Slight facetal hypertrophy is noted at this level.
A posteriorly herniated disc with peridiscal osteophytes is noted at the L4-L5 level, with bilateral neural foraminal narrowing and impingement of the right L4 nerve root in the right neural foramen at the L4-L5 level. There is severe facetal and ligamentum flavum hypertrophy with canal stenosis.
A small posterior disc bulge with peridiscal osteophytes is noted at the L3-L4 level with slight facetal hypertrophy.
Left and right postero-lateral disc bulges with peridiscal osteophytes are noted at the L2-L3 level.
Bilateral far lateral disc bulges are noted at the L3-L4 and L4-L5 levels and on the right side at the L2-L3 level.
Type II degenerative marrow changes are noted adjacent to the L2-L3 and L3-L4 intervertebral discs. The lumbar vertebral bodies show spotty fatty marrow changes. The L1 vertebral body appears slightly wedged, centrally.
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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
IMPRESSION :
1. A small, postero-central disc herniation at the L5-S1 level, indenting the traversing S1 nerve roots bilaterally with slight facetal hypertrophy at this level.
2. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level, impinging the right L4 nerve root in the right neural foramen at the L4-L5 level with severe facetal and ligamentum flavum hypertrophy and canal stenosis at this level.
..3/.
- 3 - Scan-00007
3. A small posterior disc bulge with peridiscal osteophytes at the L3-L4 level with slight facetal hypertrophy.
4. Left and right postero-lateral disc bulges with peridiscal osteophytes at the L2-L3 level.