sb/hs/rp/nl


Name of the Patient : Abc Xyz. R. Marlmn / M / 59 yrs.
Referred by : Dr. Abc Xyzla.
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.

SOME IMAGES SHOW PATIENT MOTION.

OBSERVATION :

There is reduction in height of the L2-L3 disc and loss of water content of the lumbar intervertebral discs.

There is a posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. There is indentation upon the traversing L5 nerve roots bilaterally.

A smaller, postero-central disc herniation with peridiscal osteophytes is noted at the L5-S1 level indenting the traversing S1 nerve roots bilaterally.

A fairly large, right paracentral disc herniation with peridiscal osteophytes is noted at the D12-L1 level, with right neural foraminal narrowing and indentation upon the right L1 nerve root.
Scan-00005

A posterior disc bulge with right postero-lateral and far lateral disc herniations with peridiscal osteophytes are noted at the L2-L3 level with right neural foraminal narrowing and indentation on the extraforaminal segment of the exiting right L2 nerve root. A left far lateral disc herniation is also noted at this level.

A small, postero-central disc herniation with peridiscal osteophytes is noted at the L1-L2 level and a small posterior disc bulge with peridiscal osteophytes is noted at the L3-L4 level.

Small posterior disc bulges with peridiscal osteophytes are also noted at the D10-D11 and D11-D12 levels.

Bilateral far lateral disc bulges are noted over the L3-L4 to L5-S1 levels.

Facetal hypertrophy is noted in the lumbar region, with facet joint effusion at the L2-L3 and L3-L4 levels on the right and at the L4-L5 level, bilaterally. Slight ligamentum flavum hypertrophy is noted at the L4-L5 level.

Type II, degenerative marrow changes are seen adjacent to the L2-L3, L3-L4 and L4-L5 intervertebral discs.

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 :

12.0 mm at L1-L2
14.0 mm at L2-L3
..3/.








- 3 - Scan-00005

13.0 mm at L3-L4
8.0 mm at L4-L5
7.0 mm at L5-S1.

IMPRESSION :

1. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 with indentation upon the traversing L5 nerve roots bilaterally.

2. A smaller, postero-central disc herniation with peridiscal osteophytes at the L5-S1 level indenting the traversing S1 nerve roots bilaterally.

3. A fairly large, right paracentral disc herniation with peridiscal osteophytes at the D12-L1 level indenting the right L1 nerve root.

4. A posterior disc bulge with right postero-lateral and far lateral disc herniations with peridiscal osteophytes at the L2-L3 level with indentation on the extraforaminal segment of the exiting right L2 nerve root. A left far lateral disc herniation is also noted at this level.

5. A small, postero-central disc herniation with peridiscal osteophytes at the L1-L2 level and a small posterior disc bulge with peridiscal osteophytes at the L3-L4 level.

6. Facetal hypertrophy in the lumbar region.

7. Slight ligamentum flavum hypertrophy at the L4-L5 level.

8. Tight lumbar canal at L4-L5 and L5-S1 levels.