sb/ke/rg.
Date : 00.00.00
Name of the Patient : Abc Xyza lmn / F / 36 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 00.00.00.
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 L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is a fairly large posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing L5 nerve roots bilaterally, more on the right side. Slight facetal and ligamentum flavum hypertrophy is also noted at this level with resultant canal stenosis.
A small postero-central disc herniation with peridiscal osteophytes is noted at the L3-L4 level indenting the dural theca anteriorly. Slight facetal hypertrophy is also noted at this level.
A small postero-central protruded disc is noted at the L5-S1 level.
Type I/II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.
..2/.
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 S1 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
15.0 mm at L3-L4
9.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
1. A fairly large posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc fragment indenting the traversing L5 nerve roots bilaterally, more on the right side. Slight facetal and ligamentum flavum hypertrophy is also noted at this level with canal stenosis.
2. A small postero-central disc herniation with peridiscal osteophytes at the L3-L4 level with slight facetal hypertrophy at this level.
3. A small postero-central protruded disc at the L5-S1 level.