ke/bv/nl/rg.

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

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE and 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 :

The lumbar intervertebral discs show loss of water content.

There is scoliosis of the lumbar spine with convexity to the left. Slight retroplacement of the L5 over the S1 vertebral body is seen. There is right lateral wedging of the L3 and L4 vertebral bodies with clockwise rotation of the lumbar vertebrae. Right lateral peridiscal osteophytes are seen at the L3-L4 level.

There are posterior and bilateral far lateral disc herniations at the L4-L5 and L5-S1 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is mild indentation upon the extraforaminal portion of the left L5 nerve root and the extraforaminal portion of the right L4 and L5 nerve roots.

The L3-L4, L4-L5 and L5-S1 facet joints bilaterally show degenerative changes. Effusion is seen within the right facet joints at the L4-L5 and L5-S1 levels.


There is a right far lateral disc bulge at the L3-L4 level and left far lateral disc bulge at the L2-L3 level. Posterior peridiscal osteophytes are seen at the L3-L4, L4-L5 and L5-S1 levels.

Focal fatty changes are noted in the L4 and L5 vertebral bodies with Type I degenerative changes in the L3, L4, L5 and S1 vertebral bodies.

The rest of the lumbar vertebral bodies 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-L2 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 :

17.0 mm at L1-L2
17.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

1. Scoliosis of the lumbar spine with convexity to the left.

2. Slight retroplacement of the L5 over the S1 vertebral body.

3. Posterior and bilateral far lateral disc herniations at the L4-L5 and L5-S1 levels with mild indentation upon the extraforaminal portion of the left L5 nerve root and the extraforaminal portion of the right L4 and L5 nerve roots.
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4. A right far lateral disc bulge at the L3-L4 level and a left far lateral disc bulge at the L2-L3 level.

5. Facetal arthropathy at the L3-L4, L4-L5 and L5-S1 levels bilaterally with effusion within the right facet joint at the L4-L5 and L5-S1 levels.