sb/ke/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzli Qurlmn / M / 49 yrs.
Referred by : Dr. Abc Xyzsari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 2 years.
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 loss of water content of the L3-L4, L4-L5 intervertebral discs.
There is a fairly large posteriorly herniated disc with a peridiscal osteophyte at the L4-L5 level with thecal sac compression. Slight inferior migration of the disc fragment is noted. There is slight facetal and ligamentum flavum hypertrophy and resultant canal stenosis at that level.
A postero-central disc herniation with peridiscal osteophytes is noted at the L3-L4 level indenting the dural theca anteriorly and right neural foraminal narrowing. Slight facetal hypertrophy is noted at the L3-L4 and L5-S1 levels.
A hemangioma with fat content is noted in the L4 and D12 vertebral bodies.
The pedicles of the lower lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
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Fat is noted in the filum terminale in the lower lumbar region.
There is seen a well-defined, cystic lesion, measuring approximately 1.2 mm diameter along the posterior margin of the left psoas muscle at the L4-L5 disc level. This lesion is of ? etiology (scan 106.7 & 104.10).
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L2 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 :
14.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
IMPRESSION :
1. A fairly large posteriorly herniated disc with a peridiscal osteophyte at the L4-L5 level with slight inferior migration of the disc fragment. There is slight facetal and ligamentum flavum hypertrophy and resultant canal stenosis at that level.
2. A postero-central disc herniation with peridiscal osteophytes at the L3-L4 level with right neural foraminal narrowing and a tight canal at that level.
3. Slight facetal hypertrophy at the L3-L4 and L5-S1 levels.
4. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions.