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Date : 00.00.00

Name of the Patient : Abc Xyz Slmn / M / 66 yrs.
Referred by : Dr. Abc Xyzlsara.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O pain in the left groin since 6-7 months which has incresed since 10 days.
H/O Ca of the right lung. Received 12 cycles of Chemotherapy.

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.

Minimal forward translation of the L4 over the L5 vertebra is noted without obvious spondylolysis at L4.

There is a small postero-central protruded disc at the L5-S1 level with a left far lateral disc bulge with peridiscal osteophytes at this level.

A left postero-lateral disc herniation with peridiscal osteophytes is noted at the L4-L5 level with left neural foraminal narrowing and indentation on the foraminal segment of the left L4 nerve root. Slight facetal hypertrophy is noted at this level, more so on the left side, with left lateral recess stenosis.


A left and right postero-lateral disc herniation is noted at the L3-L4 level with bilateral neural foraminal narrowing and indentation on the extraforaminal segment of the left L3 nerve root.

A posterior and right postero-lateral disc bulge with peridiscal osteophytes is noted at the L2-L3 level with slight right neural foraminal narrowing.

There is slight anterior wedging of the D11 vertebral body without change in signal intensity.

A well-marginated, approximately 2.0 x 1.5 cms sized intermediate signal intensity lesion on the T1 Weighted images is noted in the right paravertebral region (most likely in close relation to the right 12th rib). This lesion appears hyperintense on the T2 Weighted images. A similar signal intensity lesion measuring approximately 9.0 mm in diameter is noted along the right lateral margin of the L5 spinous process (scans 106.2 & 104.2).

The lumbar vertebral bodies reveal normal signal intensity.
Anterior disc herniations with anterior peridiscal osteophytes are noted in the dorso-lumbar and lumbar regions.

The facet joints at the L5-S1 and L2-L3 levels also appear slightly hypertrophied.

The visualized pre and left paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.
..3/.










- 3 - Scan-00004

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

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

IMPRESSION :

1. A small postero-central protruded disc at the L5-S1 level with a left far lateral disc bulge with peridiscal osteophytes at this level.

2. A left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with left neural foraminal narrowing and indentation on the foraminal segment of the left L4 nerve root. Slight facetal hypertrophy is noted at this level, more so on the left side, with left lateral recess stenosis.

3. A left and right postero-lateral disc herniation at the L3-L4 level with bilateral neural foraminal narrowing and indentation on the extraforaminal segment of the left L3 nerve root.

4. A posterior and right postero-lateral disc bulge with peridiscal osteophytes at the L2-L3 level.

5. A well-marginated, approximately 2.0 x 1.5 cms sized lesion in the right paravertebral region (most likely in close relation to the right 12th rib) is not specific for a single etiology. This lesion may represent a metastatic lesion (in view of H/O Ca of right lung).

A smaller lesion of similar signal along the right lateral margin of the L5 spinous process is ? metastatis ?? inflammatory cyst.

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