Name of the Patient : Abc Xyz Klmn / M / 20 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain 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 appears to be partial sacralization of the L5 vertebra on the right side and the L2 vertebra is as marked on the film. Please correlate with plain radiographs.

There is scoliosis of the lumbar spine with convexity to the right.

A large postero-central disc extrusion with peridiscal osteophytes is seen to compress the thecal sac at the L4-L5 level. A left far lateral disc herniation is seen at this level. This intervertebral disc is markedly dessicated. There is mild facetal arthropathy with resultant central and lateral canal stenosis at this level.

Mild posterior and left postero-lateral disc bulges are noted at the L3-L4 level.
Scan-00009


The L2-L3 and L3-L4 facet joints also show hypertrophic degenerative changes with probable effusion within the right facet joints at the L3-L4 and L4-L5 levels. Facetal hypertrophy is noted at the L1-L2 level. Also seen is mild ligamentum flavum hypertrophy in the lumbar region.

Far lateral disc bulges are seen bilaterally at the L1-L2, L2-L3 and L3-L4 levels and on the right side at the L3-L4 level.

The pedicles of the lower lumbar vertebrae appear to be congenitally short in their antero-posterior dimensions.

The D11-D12 and D12-L1 intervertebral discs show mild loss of water content.

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 D12-L1 level and the thecal sac terminates at the S1-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
16.0 mm at L2-L3
15.0 mm at L3-L4
5.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. Partial sacralization of the L5 vertebra on the right side.
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2. A large postero-central disc extrusion with peridiscal osteophytes with resultant canal stenosis at the L4-L5 level with a left far lateral disc herniation at this level.

3. Mild posterior and left postero-lateral disc bulges at the L3-L4 level.

4. Hypertrophic facetal arthropathy at the L2-L3 and L3-L4 levels and facetal arthropathy at the L4-L5 level.

5. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions.