ke/bv/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzi Vlmn / F / 60 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 3-4 months.
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 :
The lumbar intervertebral discs show loss of water content.
There is scoliosis of the lumbar spine with convexity to the right. Lateral subluxation of L3 over L4 is also noted with lateral peridiscal osteophytes.
There is a posterior and right far lateral disc herniation at the L5-S1 level with anterior indentation of the thecal sac and the extraforaminal portion of the traversing right L5 nerve root.
A diffuse posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. A part of the disc is seen to migrate inferiorly posterior to the L5 vertebra with indentation upon the right L5 nerve root (scans 105.4, 104.6, 102.5). A right far lateral disc bulge is also noted at this level with indentation upon the foraminal and extraforaminal portion of the traversing right L4 nerve root.
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- 2 - Scan-00003
There is a posterior and left far lateral disc herniation at the L3-L4 level with anterior indentation of the thecal sac and left neural foraminal narrowing. Mild indentation upon the foraminal and extraforaminal portion of the left L3 nerve root is noted.
A small posterior and right far lateral disc bulge is seen at the L2-L3 level. Anterior disc herniations are seen over the L2-L3 to L5-S1 levels with anterior and posterior peridiscal osteophytes.
The lumbar facet joints show slight degenerative changes. Ligamentum flavum hypertrophy is seen at the L5 level.
Focal fatty changes are seen in the lumbar vertebral bodies.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
16.0 mm at L2-L3
13.0 mm at L3-L4
9.0 mm at L4-L5
9.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Scoliosis of the lumbar spine with convexity to the right.
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- 3 - Scan-00003
2. A posterior and right far lateral disc herniation at the L5-S1 level indenting the extraforaminal portion of the traversing right L5 nerve root.
3. A diffuse posterior disc herniation at the L4-L5 level with a part of the disc seen to migrate inferiorly
posterior to L5 indenting the right L5 nerve root with a right far lateral disc bulge indenting the foraminal and extraforaminal portion of the traversing right L4 nerve root at this level.