sb/ke/nl/rg.

Name of the Patient : Abc Xyzlmn / M / 45 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE 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 L2-L3, L3-L4 and L4-L5 intervertebral discs.

There is a small, postero-central protruded disc at the L5-S1 level.

There is a left postero-lateral disc herniation at the L4-L5 level with left neural foraminal narrowing and indentation of the traversing left L5 nerve root. Slight inferior migration of the disc is seen. The L4-L5 facet joint on the left shows hypertrophic degenerative changes.

A postero-central and right paracentral disc herniation is seen at the L3-L4 level with indentation of the traversing right L4 nerve root.

A small, postero-central disc herniation is noted at the L2-L3 level.

Posterior peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels.
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- 2 - Scan-00000

Facetal hypertrophy is seen at the L3-L4 and L4-L5 levels with slight ligamentum flavum hypertrophy at the L4-L5 level.

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 D12-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 :

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

IMPRESSION :

1. A small, postero-central protruded disc at the L5-S1 level.

2. A left postero-lateral disc herniation at the L4-L5 level with indentation of the traversing left L5 nerve root.

3. A postero-central and right paracentral disc herniation at the L3-L4 level with indentation of the traversing right L4 nerve root.

4. A small, postero-central disc herniation at the L2-L3 level.

5. Posterior peridiscal osteophytes at the L3-L4 and L4-L5 levels.

6. Facetal hypertrophy at the L3-L4 and L4-L5 levels with slight ligamentum flavum hypertrophy at the L4-L5 level with tight canal at these levels.