ke/bv/rg.
Date : 00.00.00
Name of the Patient : Abc XyzCrawlmn / F / 52 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 00.00.00.
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 slight forward translation of the L4 over the L5 vertebral body.
The L2-L3 intervertebral disc is reduced in height and the lumbar intervertebral discs show loss of water content.
A posterior and right postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac. There is hypertrophy of the facet joints at this level.
A posterior and right far lateral disc herniation with posterior peridiscal osteophytes is noted at the L5-S1 level. Mild indentation upon the extraforaminal portion of the traversing right L5 nerve root is seen.
Small posterior disc herniations are noted at the L2-L3 and L3-L4 levels with a left far lateral disc herniation at the L2-L3 level.
A posterior disc bulge is seen at the L3-L4 level.
..2/.
Small anterior disc herniations are seen at the L2-L3 and L4-L5 levels. Small posterior peridiscal osteophytes are noted over the L1-L2 to the L4-L5 levels.
The L3-L4 and L5-S1 facet joints also show degenerative changes.
Type II degenerative changes are noted in the L2, L3, L4, L5 and S1 vertebral bodies adjacent to the L2-L3, L3-L4 and L4-L5 and L5-S1 intervertebral discs.
The L1 vertebral body reveals normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
Small paraaortic lymphnodes are seen in the lumbar region.
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 :
17.0 mm at L1-L2
15.0 mm at L2-L3
16.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Forward translation of the L4 over the L5 vertenra.
2. A posterior and right far lateral disc herniation at the L4-L5 level.
3. A posterior and right far lateral disc herniation with posterior peridiscal osteophytes at the L5-S1 level.
4. Facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels.