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ke/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzl Galmn / M / 75 yrs.
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE 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 a large, diffuse, posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show mild degenerative changes. Ligamentum flavum hypertrophy is also noted with resultant severe canal stenosis at this level.

A posterior and bilateral far lateral disc bulge with peridiscal osteophyte is seen at the L5-S1 level, with bilateral neural foraminal narrowing.

A right and left postero-lateral disc bulge is seen at the L3-L4 level with bilateral neural foraminal narrowing.

Small posterior disc bulges are noted at the L1-L2 and L2-L3 levels. Anterior disc herniations are seen in the lower dorsal and lumbar region. Schmorls nodes are also noted in the lumbar region. The lumbar intervertebral discs show loss of water content. Hypointense areas are seen within the L4-L5 disc on all the pulse sequences which would represent calcification/vacuum phenomena.

Type II degenerative changes are seen in the lumbar vertebral bodies adjacent to the intervertebral disc with slight anterior wedging of the D12, L1 and L2 vertebral bodies.

The lumbar facet joints show mild degenerative changes.
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 :

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

Incidental note is made of large cortical cyst in the upper pole of the right kidney.

IMPRESSION :

The MRI features are suggestive of degenerated lumbar spine with :

1. A large, diffuse, posterior disc herniation at the L4-L5 level with bilateral neural foraminal narrowing, facetal arthropathy, ligamentum flavum hypertrophy with resultant severe canal stenosis at this level.
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2. A posterior and bilateral far lateral disc bulge with peridiscal osteophyte at the L5-S1 level.

3. A right and left postero-lateral disc bulge at the L3-L4 level.

4. Small posterior disc bulges at the L1-L2 and L2-L3 levels.


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