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Date : 00.00.00

Name of the Patient : Abc XyzDwarlmn / M / 55 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE (left more than right) with paresthesias since December 0000.

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 slight retrolisthesis of the L2 vertebra over the L3 vertebra. A posterior disc herniation, more to the right of the midline is seen at the L2-L3 level with anterior indentation upon the thecal sac and slight neural foraminal narrowing, bilaterally.

A posterior disc bulge and a left far lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and mild left neural foraminal narrowing with indentation upon the exiting left L3 nerve root.

Small posterior disc herniations are noted at the L1-L2 and L5-S1 levels with mild bilateral neural foraminal narrowing at these levels. A posterior disc bulge is seen at the L4-L5 level.

The L1-L2, L2-L3, L3-L4 and L5-S1 intervertebral discs show loss of water content.


The L4-L5 and L5-S1 facet joints show degenerative changes. Bilateral far lateral (extraforaminal) disc bulges are seen at the L2-L3, L4-L5 and L5-S1 levels.

Focal fatty changes are noted in the lumbar vertebrae.

The rest of the facet joints and 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 level.

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

14.0 mm at L1-L2
10.0 mm at L2-L3
11.0 mm at L3-L4
11.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Slight retrolisthesis of the L2 vertebra over the L3 vertebra.

2. A posterior disc herniation, more to the right of the midline at the L2-L3 level.

3. A posterior disc bulge and a left far lateral disc herniation at the L3-L4 level.

4. Small posterior disc herniations at the L1-L2 and L5-S1 levels.

5. A tight spinal canal in the lumbar region.








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