Date : 00.00.00
Name of the Patient : Abc Xyz Bholmn / F / 54 yrs.
Referred by : Dr. Abc Xyzosale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 1 year.
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.
FEW IMAGES SHOW PATIENT MOTION.
There is sacralization of the L5 vertebra and the L4 vertebra is as marked on the film.
There is minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina with impingement of the exiting L4 nerve roots at the L4-L5 level.
A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L3-L4 level.
There is a right postero-lateral and right far lateral disc herniation at the L2-L3 level. Facetal hypertrophy is seen at this level.
The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes. Ligamentum flavum hypertrophy is seen at the L4-L5 and L5 levels.
There are bilateral far lateral (extraforaminal) disc herniations at the L3-L4 and L4-L5 levels.
The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies reveal normal signal intensity. 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 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
15.0 mm at L2-L3
11.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.
The cervico-dorsal spine was screened with 5 mm thick T1 Weighted sagittal images and does not reveal any significant feature of note.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
3. A posterior disc herniation with impingement of the exiting L4 nerve roots at the L4-L5 level.
4. A small posterior disc herniation at the L3-L4 level.
- 3 - Scan-00004
5. A right postero-lateral and right far lateral disc herniation with facetal hypertrophy at the L2-L3 level.
6. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels.
7. Ligamentum flavum hypertrophy at the L4-L5 and L5 levels.