sb/hs/rg.
Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 49 yrs.
Referred by : Dr. Abc Xyzas.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache.
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 vertebra over the L5 vertebra. Also seen is mild retroplacement of the L5 vertebra over the S1 vertebra.
There is loss of water content of all the lumbar intervertebral discs except for the L2-L3 disc.
There are posterior and bilateral far lateral disc herniations with posterior peridiscal osteophytes at the L5-S1 level with bilateral neural foraminal narrowing. Also seen is indentation upon the traversing left S1 nerve root and both the exiting L5 nerve roots.
There is a posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing. There is also hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with resultant canal stenosis at this level. Bilateral far lateral (extraforaminal) disc herniations are noted at this level.
A right postero-lateral disc herniation is seen to narrow the right neural foramen at the L3-L4 level. A right far lateral (extraforaminal) disc herniation is also noted at this level.
Right postero-lateral and right far lateral disc bulges are seen at the L2-L3 level.
Facetal hypertrophy is noted in the rest of the lumbar region. Ligamentum flavum hypertrophy is seen at the L5-S1 level.
Fat is noted in the filum terminale over the L2 to S1 vertebral levels.
Spotty fatty marrow changes are noted in the lumbar vertebrae.
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
17.0 mm at L2-L3
16.0 mm at L3-L4
8.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. Slight forward translation of the L4 vertebra over the L5 vertebra and mild retroplacement of the L5 vertebra over the S1 vertebra.
2. Posterior and bilateral far lateral disc herniations with posterior peridiscal osteophytes at the L5-S1 level with indentation upon the traversing left S1 nerve root and both the exiting L5 nerve roots.
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3. A posteriorly herniated disc at the L4-L5 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy.
4. A right postero-lateral disc herniation at the L3-L4 level.
5. Facetal hypertrophy in the rest of the lumbar region.
6. Bilateral far lateral disc herniations at the L4-L5 level and on the right side at the L3-L4 level.
7. Severe lumbar canal stenosis at the L4-L5 level and mild canal stenosis at the L5-S1 level.