Name of the Patient : Abc Xyzt N. Kilalmn / M / 75 yrs.
Referred by : Dr. Abc Xyzospital.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE 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 probable sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.

There is slight scoliosis of the lumbar spine with convexity to the left and mild retroplacement of the L2 over the L3 and L3 over the L4 vertebrae.

There is a diffuse posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level indenting the thecal sac anteriorly and causing bilateral neural foraminal narrowing. Slight inferior migration of the disc is seen on the right side and indenting the traversing right L5 nerve root. A right far lateral disc herniation is also noted at this level with mild indentation upon the extraforaminal portion of the exiting right L4 nerve root.






Posterior disc bulge and left far lateral disc herniations are seen at the L2-L3 and L3-L4 levels with anterior indentation of the thecal sac and mild indentation upon the extraforaminal portion of the exiting left L2 and L3 nerve roots, respectively. Right far lateral disc bulges are seen at these levels.

Small posterior peridiscal osteophytes are noted at the L1-L2, L2-L3 and L3-L4 levels.

The lumbar facet joints show degenerative changes. Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.

Anterior disc herniations are noted at the L2-L3, L3-L4 and L4-L5 levels.

The lumbar intervertebral discs show loss of water content.

Diffuse fatty changes are noted in the lumbar vertebrae suggestive of osteoporosis.

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 follow :

16.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
14.0 mm at L4-L5
12.0 mm at L5-S1.
..3/.











IMPRESSION :

1. Probable sacralization of the L5 vertebra. Please correlate with plain radiographs.

2. Scoliosis of the lumbar spine with convexity to the left and mild retroplacement of the L2 over the L3 and L3 over the L4 vertebrae.

3. A diffuse posterior disc herniation with posterior peridiscal osteophytes at the L4-L5 level slight inferior migration of the disc on the right side and indenting the traversing right L5 nerve root. A right far lateral disc herniation is also noted at this level with mild indentation upon the extraforaminal portion of the exiting right L4 nerve root.

4. Posterior disc bulge and left far lateral disc herniations at the L2-L3 and L3-L4 levels with mild indentation upon the extraforaminal portion of the exiting left L2 and L3 nerve roots, respectively.

5. Facetal arthropathy in the lumbar region.