Date : 00.00.00
Name of the Patient : Abc Xyzrrao Lolmn / M / 76 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating occasionally to BLE since 2 years.
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.
There is partial sacralization of the L5 vertebra on the left side and the L1 vertebra is as marked on the film.
There is forward translation of the L4 vertebra over the L5 vertebra without any obvious spondylolysis.
A large posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac, bilateral neural foraminal narrowing and impingement of the exiting L4 nerve roots. The L4-L5 facet joints show severe hypertrophic degenerative changes. Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.
There is a posterior disc herniation at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is mild indentation on the exiting right L3 nerve root.
Bilateral far lateral (extraforaminal) disc herniations are seen at the L3-L4 and L4-L5 levels.
- 3 - Scan-00002
Mild facetal hypertrophy is seen at the L2-L3 and L3-L4 levels.
The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies reveal normal signal intensity. The remaining 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 :
15.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
8.0 mm at L4-L5
6.0 mm at L5-S1.
1. Partial sacralization of the L5 vertebra on the left side.
2. Forward translation of the L4 vertebra over the L5 vertebra.
3. A large posterior disc herniation at the L4-L5 level with impingement of the exiting L4 nerve roots with severe hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with severe canal stenosis at this level.
4. A posterior disc herniation at the L3-L4 level with mild indentation on the exiting right L3 nerve root.
5. Bilateral far lateral (extraforaminal) disc herniations at the L3-L4 and L4-L5 levels.