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Date : 00.00.00
sb/hs
Name of the Patient : Abc Xyz A. Chalmn / F / 58 yrs.
Referred by : Dr. Abc Xyzgrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in BLE, right more than left since 6 months.

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.

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

There is loss of water content of the lumbar intervertebral discs.

There is a small postero-central disc herniation at the L5-S1 level. The L4-L5 and L5-S1 facet joints show degenerative changes.

There is a posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing. There is ligamentum flavum hypertrophy and canal stenosis.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualised pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the D12 level and the thecal sac terminates at the S1 level.

Anterior disc herniations with peridiscal osteophytes are seen in the upper lumbar region.



The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

17.0 mm at L1-L2

19.0 mm at L2-L3

17.0 mm at L3-L4

10.0 mm at L4-L5

11.0 mm at L5-S1.

IMPRESSION :

1. Minimal forward translation of the L4 vertebra over the L5 vertebra.

2. A small postero-central disc herniation at the L5-S1 level.

3. A posteriorly herniated disc at the L4-L5 level with ligamentum flavum hypertrophy and canal stenosis.

4. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.


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