sb/bv/nl/nl

Name of the Patient : Abc Xyzssa Insalmn / F / 38 yrs.
Referred by : Dr. Abc Xyzonawalla.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain 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 vertebra.

There is loss of water content of the L3-L4 and L4-L5 intervertebral discs.

There is a small, posterior disc bulge at the L5-S1 level with minimal indentation upon the traversing left S1 nerve root. Facetal hypertrophy is noted at this level.

There is a posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Facetal and ligamentum flavum hypertrophy is also noted at this level, with canal stenosis.

A posterior and right far lateral disc bulge is noted at the L3-L4 level with facetal hypertrophy at this level, bilaterally.

A right far lateral disc bulge is noted at the L2-L3 level.

Lateral peridiscal osteophytes are seen in the lumbar region.

Facetal hypertrophy is noted at the L1-L2 and L2-L3 levels.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :

13.0 mm at L1-L2
12.0 mm at L2-L3
11.0 mm at L3-L4
6.0 mm at L4-L5
6.0 mm at L5-S1.

IMPRESSION :

1. Sacralization of the L5 vertebra.

2. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with facetal and ligamentum flavum hypertrophy, with canal stenosis.

3. A small, posterior disc bulge at the L5-S1 level with minimal indentation upon the traversing left S1 nerve root with facetal hypertrophy at this level.

4. A posterior and right far lateral disc bulge with facetal hypertrophy bilaterally at the L3-L4 level.

5. Facetal hypertrophy at the L1-L2 and L2-L3 levels.