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sb/ke/nl.rg.
Date : 00.00.00

Name of the Patient : Abc Xyzati K. Palmn / F / 57 yrs.
Referred by : Dr. Abc Xyzli.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O paresthesias in the left foot since 20 days.

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 reduction in height of the L5-S1 intervertebral disc and loss of water content of the lumbar intervertebral discs.

There is a left postero-lateral and left far lateral disc herniation with peridiscal osteophytes at the L5-S1 level with left neural foraminal narrowing and indentation on the extraforaminal portion of the left L5 nerve root. A right far lateral disc herniation is also noted at this level.

Small posterior disc bulges with peridiscal osteophytes is noted at the L4-L5 and L3-L4 levels.

Facetal hypertrophy is noted in the dorso-lumbar and lumbar regions and ligamentum flavum hypertrophy is noted at the L4-L5 and L5-S1 levels.

Type II degenerative marrow changes are noted adjacent to the L5-S1 disc.


The rest of the lumbar vertebral bodies reveal normal signal intensity. 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 :

18.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. A left postero-lateral and left far lateral disc herniation with peridiscal osteophytes at the L5-S1 level with indentation on the extraforaminal segment of the left L5 nerve root. A right far lateral disc herniation is also noted at this level.

2. Small posterior disc bulges with peridiscal osteophytes at the L4-L5 and L3-L4 levels.

3. Facetal hypertrophy in the dorso-lumbar and lumbar regions and ligamentum flavum hypertrophy at the L4-L5 and L5-S1 levels with left lateral recess stenosis at the L5-S1 level.




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