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ke/sb/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Blmn / M / 59 yrs.
Referred by : Dr. Abc Xyzspati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache (on & off).

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 a small posterior and a right postero-lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and right neural foraminal narrowing. There is resultant indentation upon the foraminal portion of the right L4 nerve root. The L4-L5 facet joints bilaterally show hypertrophic degenerative changes, left more than right. Mild ligamentum flavum hypertrophy is also seen at this level with resultant tight canal.

The L3-L4 facet joints bilaterally and the L5-S1 facet joint on the left side also show, hypertrophic degenerative changes.

The L3-L4 and L4-L5 intervertebral discs show loss of water content.

Anterior disc herniations with large peridiscal osteophytes are seen in the lower dorsal and lumbar region.

Type II degenerative changes are noted in the antero- superior portion of the L2, L4 and L5 vertebral bodies.


The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and 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 :

14.0 mm at L1-L2
15.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A small posterior and right postero-lateral disc herniation at the L4-L5 level with hypertrophic facetal arthropathy, bilaterally and resultant tight canal at this level.

2. Hypertrophic facetal arthropathy at the L3-L4 level bilaterally and at the L5-S1 level on the left side.

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