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sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyzasad Kalmn / M / 50 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyztankar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to the LLE 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 loss of water content of the L1-L2, L4-L5 and L5-S1 intervertebral discs.

There is a fairly large, posteriorly extruded disc at the L4-L5 level with thecal sac compression and indentation on the L5 nerve roots bilaterally. Inferior migration of the disc fragment is noted along the posterior margin of the L5 vertebral body, indenting the dural theca anteriorly.

A postero-central disc herniation is noted at the L5-S1 level indenting the dural theca anteriorly.

A small posterior disc bulge with a right postero-lateral and right far lateral disc herniation is noted at the L3-L4 level indenting the extraforaminal segment of the right L3 nerve root.

Posterior peridiscal osteophytes are noted in the lumbar region.




Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.

The pedicles of the lower lumbar vertebrae are congenitally short in their antero-posterior dimensions.

Fat is noted in the filum terminal over the L3 to S2 vertebral levels.

Schmorls nodes are noted in the lumbar region.

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 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
15.0 mm at L2-L3
13.0 mm at L3-L4
8.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A fairly large, posteriorly extruded disc at the L4-L5 level with indentation on the L5 nerve roots bilaterally and inferior migration of the disc fragment along the posterior margin of the L5 vertebral body.
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- 3 - Scan-00009



2. A postero-central disc herniation at the L5-S1 level.

3. A small posterior disc bulge with a right postero-lateral and right far lateral disc herniation at the L3-L4 level indenting the extraforaminal segment of the right L3 nerve root.

4. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions.

5. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels with canal stenosis at these levels.

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