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sb/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyznt Klmn / M / 60 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to the RLE with paresthesias 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 loss of water content of the lumbar intervertebral discs.

There is a fairly large, right paracentral extruded disc at the L4-L5 level with small peridiscal osteophytes with inferior migration of the disc fragment into the right lateral recess of L5 indenting the traversing right L5 nerve root. There is also bilateral neural foraminal narrowing.

A small postero-central protruded disc with bilateral far lateral disc bulges is noted at the L5-S1 level.

The pedicles of the L4 and L5 vertebrae appear congenitally short in their antero-posterior dimensions. Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.

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


The lumbar vertebral bodies reveal spotty fatty changes. The rest of the 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 :

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

IMPRESSION :

1. A fairly large, right paracentral extruded disc at the L4-L5 level with inferior migration of the disc fragment into the right lateral recess of L5, indenting the traversing right L5 nerve root.

2. Congenitally short pedicles of the L4 and L5 vertebrae in their antero-posterior dimensions with canal stenosis at L4-L5 and L5-S1 levels.

3. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels.

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