ke/hs/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyz Shahlmn / F / 40 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE and numbness.
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 forward subluxation of the L4 vertebra over the L5 vertebra. A pseudoposterior disc bulge is noted at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints bilaterally show hypertrophic degenerative changes with minimal effusion.
A posterior and a left far lateral disc herniation is seen at the L5-S1 level with anterior indentation of the thecal sac, left neural foraminal narrowing and indentation upon the extraforaminal portion of the exiting left L5 nerve root.
Posterior and bilateral far lateral disc bulges are seen at the L3-L4 level.
Posterior and right far lateral disc herniations are noted at the L2-L3 level with anterior indentation of the thecal sac and extraforaminal portion of the exiting right L2 nerve root. Posterior peridiscal osteophytes are also noted at this level.
The lumbar intervertebral discs except the L1-L2 disc show loss of water content.
There is ligamentum flavum hypertrophy at the L4-L5 and L5 levels.
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-L2 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
12.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
1. Forward subluxation of the L4 vertebra over the L5 vertebra.
2. A pseudoposterior disc bulge at the L4-L5 level and hypertrophic facetal arthropathy with minimal effusion at this level.
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3. Posterior and left far lateral disc herniations at the L5-S1 level with indentation upon the extraforaminal portion of the exiting left L5 nerve root.
3. Posterior and bilateral far lateral disc bulges at the L3-L4 level.
4. Posterior and right far lateral disc herniations at the L2-L3 level. Also seen are posterior peridiscal osteophytes at this level.