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Name of the Patient : Abc Xyzn Ali Mlmn / M / 57 yrs.
Referred by : Dr. Abc Xyzrkar
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE since 2 months.
H/O pulmonary kochs 6 months back. Completed AKT.

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 large left far lateral disc herniation at the L3-L4 level with left neural foraminal narrowing and impingement of the extraforaminal portion of the left L3 nerve root.

A large left far lateral disc herniation is also noted at the L2-L3 level with indentation upon the extraforaminal portion of the left L2 nerve root.

There is slight retroplacement of the L4 over the L5 vertebral body. A pseudo-posterior and right far lateral disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac, right neural foraminal narrowing and indentation upon the extraforaminal portion of the right L4 nerve root.
..2/.








- 2 - Scan-00006



The L2-L3, L3-L4 and the L4-L5 facet joints show degenerative changes. Ligamentum flavum hypertrophy is noted at the L5 level.

The L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content.

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 :

19.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
16.0 mm at L4-L5
13.0 mm at L5-S1.

IMPRESSION :

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

2. A large left far lateral disc herniation at the L3-L4 level impinging the extraforaminal portion of the left L3 nerve root.
..3/.











- 3 - Scan-00006



3. A large left far lateral disc herniation at the L2-L3 level with indentation upon the extraforaminal portion of the left L2 nerve root.

4. Slight retroplacement of the L4 over the L5 vertebral body with a pseudo-posterior and right far lateral disc herniation at the L4-L5 level indenting the extraforaminal portion of the right L4 nerve root.

5. Facetal arthropathy at the L2-L3, L3-L4 and L4-L5 levels.

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