Date : 00.00.00
Name of the Patient : Abc Xyz. lmn / M / 59 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 9 months.
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.
There is loss of water content of the L2-L3 and L4-L4 intervertebral discs.
A small posterior disc bulge is noted at the L4-L5 level.
Small left and right postero-lateral disc bulges are noted at the L3-L4 level with bilateral neural foraminal narrowing. Minimal indentation on the traversing right L4 nerve is noted (scans 104.15).
A small right far lateral disc herniation is noted at the L2-L3 level with minimal indentation on the extraforaminal portion of the right L2 nerve root. A small postero-lateral disc bulge is also noted at this level.
Small posterior peridiscal osteophytes are noted at the L2-L3, L3-L4 and L4-L5 levels.
Slight facetal hypertrophy is noted at the L4-L5 level.
The lumbar vertebral bodies show spotty fatty marrow changes.
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 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
13.0 mm at L4-L5
10.0 mm at L5-S1.
1. A small posterior disc bulge at the L4-L5 level with slight facetal hypertrophy at this level.
2. Small left and right postero-lateral disc bulges at the L3-L4 level with bilateral neural foraminal narrowing with minimal indentation on the traversing right L4 nerve.
3. A small right far lateral disc herniation at the L2-L3 level with minimal indentation on the extraforaminal
right L2 nerve root.
4. Small posterior peridiscal osteophytes at the L2-L3, L3-L4 and L4-L5 levels.