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Date : 00.00.00

Name of the Patient : Abc Xyzir Gulmn / M / 48 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the LLE with slight numbness since 1 month.

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 a posterior disc bulge and a left far lateral (extraforaminal) disc herniation at the L4-L5 level with anterior indentation of the thecal sac and upon the extraforaminal portion of the exiting left L4 nerve root, respectively.

Small postero-central disc herniations with peridiscal osteophytes are noted at the L1-L2 and L2-L3 levels.

A right paracentral disc herniation is seen at the L5-S1 level with indentation upon the traversing right S1 nerve root.

The lumbar intervertebral discs except for the L3-L4 disc show loss of water content.



- 2 - Scan - 00007

The L4-L5 facet joints bilaterally and L5-S1 facet joint on the left side show degenerative changes. Hypointense signal suggestive of sclerotic changes is seen within the inferior articular facet of the L5 vertebra (?? osteoid osteoma).

Type II degenerative changes are noted in the L2 vertebral body adjacent to the L1-L2 intervertebral disc.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and 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 :

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

IMPRESSION :

1. A posterior disc bulge and left far lateral (extraforaminal) disc herniation at the L4-L5 level with indentation on the extraforaminal portion of the exiting left L4 nerve root.

2. Small posterior disc herniations with peridiscal osteophytes at the L1-L2 and L2-L3 levels.

3. A right paracentral disc herniation at the L5-S1 level.

4. Facetal arthropathy at the L4-L5 level bilaterally and at the L5-S1 level on the left.


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