sb/hs/nl/nl

Name of the Patient : Abc XyzPratappurlmn / F / 30 yrs.
Referred by : Dr. Abc Xyzpadia.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE 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 loss of water content of the L4-L5 and L5-S1 intervertebral discs.

There is a fairly large, posteriorly extruded disc, with peridiscal osteophytes at the L5-S1 level with thecal sac compression and indentation on the traversing S1 nerve roots bilaterally. Slight inferior migration of the disc fragment is noted.

There is a small, postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with slight left neural foraminal narrowing.

Hypertrophic facetal arthropathy is noted at the L3-L4 level on the left and at the L4-L5 and L5-S1 levels bilaterally, with facet joint effusion at the L5-S1 level on the right.

Type II degenerative marrow changes are noted adjacent to the L5-S1 disc.


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 S3 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

20.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
15.0 mm at L4-L5
7.0 mm at L5-S1.

Screening, T1 Weighted coronal images of the S. I. joints do not reveal any significant feature of note other than osteitis condensans ilii. No obvious abnormality is detected in the visualized gluteal regions on either side.

IMPRESSION :

1. A fairly large, posteriorly extruded disc, with peridiscal osteophytes with indentation of the traversing S1 nerve roots bilaterally with canal stenosis at the L5-S1 level.

2. A small, postero-central and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level.

3. Hypertrophic facetal arthropathy at the L3-L4 level on the left and at the L4-L5 and L5-S1 levels bilaterally, with facet joint effusion at the L5-S1 level on the right.