hs/sb/nl/rg.




/33 Date : 00.00.00

Name of the Patient : Abc Xyz. Kadlmn / F / 65 yrs.
Referred by : Dr. Abc Xyznshah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in the RLE.

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.
SOME IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There is slight forward translation of the L4 vertebra over the L5 vertebra. The lumbar intervertebral discs show loss of water content.

There is a posterior disc herniation with peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina at the L4-L5 level. A sequestered disc portion is seen to lie within the right lateral recess of the L4 vertebra with impingement of the traversing right L4 nerve root.

A posterior disc bulge is noted at the L5-S1 level. The L4-L5 and L5-S1 facet joints show degenerative changes.

A few of the dorso-lumbar vertebral bodies show areas of fatty replacement of the normal marrow.

The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

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The hip joints were screened with 5 mm thick T1 Weighted coronal images and the visualized femoral heads are unremarkable.

The conus medullaris terminates at the D12 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 :

19.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
14.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation with peridiscal osteophytes at the L4-L5 with a sequestered disc portion lying within the right lateral recess of the L4 vertebra with impingement of the traversing right L4 nerve root.

2. Facetal arthropathy at the L4-L5 and L5-S1 levels.