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hs/ke/rg/nl

Name of the Patient : Abc Xyz lmn / M / 38 yrs.
Referred by : Dr. Abc Xyz. Modi.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE.

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 Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra. The L4-L5 intervertebral disc shows loss of water content.

A posterior disc herniation is seen to compress the thecal sac and narrow both neural foramina at the L4-L5 level. The L4-L5 facet joints show hypertrophic degenerative changes with resultant canal stenosis at this level.

A posterior disc bulge is seen to indent the thecal sac at the L3-L4 level. The L3-L4 facet joints also show hypertrophic degenerative changes with resultant canal stenosis at this level.

A mild posterior disc bulge is noted at the L5-S1 level. There is an anterior disc herniation at the L3-L4 level. There is a left far lateral disc bulge at the L1-L2 level.

A limbus vertebra is seen at the L4 level with adjacent Type II degenerative changes.
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- 2 - Scan-00008


The lumbar vertebral bodies show spotty fatty marrow changes.

The rest of the lumbar 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 :

16.0 mm at L1-L2
17.0 mm at L2-L3
14.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation with hypertrophic facetal arthropathy with severe canal stenosis at the L4-L5 level.

2. A posterior disc bulge and hypertrophic facetal arthropathy with canal stenosis at the L3-L4 level.



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