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KE/SB/NL/RG.

Name of the Patient : Abc XyzShlmn / M / 53 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache radiating to BLE 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 L2 vertebra is as marked on the film.

A small left postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. The L4-L5 facet joints show mild degenerative changes.

A posterior and left postero-lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and left neural foraminal narrowing. A portion of the disc is seen to migrate inferiorly with indentation on the left L4 nerve root. Slight facetal hypertrophy is noted at this level.

A small, left far lateral disc bulge is noted at the L2-L3 level.

The lumbar intervertebral discs show loss of water content.
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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 :

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

IMPRESSION :

1. Sacralization of the L5 vertebral body and the L2 vertebra is as marked on the film.

2. A small left postero-lateral disc herniation at the L4-L5 level with mild facetal arthropathy.

3. A posterior and left postero-lateral disc herniation at the L3-L4 level with left neural foraminal narrowing. Slight inferior migration of the disc fragment is noted at this level with indentation on the left L4 nerve root. Slight facetal hypertrophy is also noted at this level.

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

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