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Name of the Patient : Abc XyzS. Hlmn / F / 55 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias.

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 sacralization of the L5 vertebral body and the L1 vertebra is as marked on the film.

There is a posterior and bilateral far lateral disc herniations with peridiscal osteophytes at the L4-L5 level with anterior indentation of the thecal sac, bilateral neural foraminal narrowing and mild indentation upon the extraforaminal portion of the right L5 nerve root. Hypertrophic facetal arthropathy and ligamentum flavum hypertrophy is noted at this level.

A left far lateral disc herniation is seen at the L3-L4 level with indentation upon the extraforaminal portion of the left L3 nerve root. The L3-L4 facet joints show hypertrophic degenerative changes with mild left neural foraminal narrowing. Mild ligamentum flavum hypertrophy is also noted at this level.
Scan-00004


A small left far lateral disc bulge is noted at the L2-L3 level. The L2-L3 and L4-L5 intervertebral discs show loss of water content.

The L1-L2 and L2-L3 facet joints show hypertrophic degenerative changes.

Type II degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc and in the antero-inferior portion of the L2 vertebral body.

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 :

15.0 mm at L1-L2
14.0 mm at L2-L3
12.0 mm at L3-L4
11.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebral body.

2. Posterior and bilateral far lateral disc herniations with peridiscal osteophytes at the L4-L5 level with mild indentation upon the extraforaminal portion of the right L5 nerve root and canal stenosis.
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3. A left far lateral disc herniation at the L3-L4 level indenting the extraforaminal portion of the left L3 nerve root.

4. A small left far lateral disc bulge at the L2-L3 level.

5. Hypertrophic facetal arthropathy at the L1-L2, L2-L3, L3-L4 and L4-L5 levels with slight ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels.

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