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ke/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzammed Mulmn / M / 72 yrs.
Referred by : Dr. Abc Xyzorude.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating 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 is slight forward translation of the L4 vertebra over the L5 vertebra.

There is a postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with anterior indentation of the thecal sac. A free fragment is seen to migrate superiorly into the right lateral recess of the L4 vertebra and superior aspect of the right neural foramen with impingement of the traversing and exiting portion of the right L4 nerve root.

There are small posterior disc herniations at the L2-L3 and L3-L4 levels with anterior indentation of the thecal sac and mild neural foraminal narrowing bilaterally at these levels.

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

Schmorls nodes are seen at the superior aspect of the L3 and L1 vertebral bodies. The lumbar intervertebral discs except for the L5-S1 disc show loss of water content.



The lumbar facet joints show mild degenerative changes. Mild ligamentum flavum hypertrophy is noted at the L4-L5 level.

The lumbar vertebral bodies 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 :

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

IMPRESSION :

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

2. A postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with canal stenosis. A free fragment is seen to migrate superiorly into the right lateral recess of the L4 vertebra and superior portion of the right L4-L5 neural foramina with impingement of the traversing and exiting portion of the right L4 nerve root.

3. Small posterior disc herniations at the L2-L3 and L3-L4 levels.

4. Mild facetal arthropathy in the lumbar region.
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