sb/hs/rg/nl

Name of the Patient : Abc Xyzben lmn / F / 60 yrs.
Referred by : Dr. Abc Xyzdhwa.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the LLE with paresthesias since 15 days.

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 lumbar intervertebral discs.

There is a posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing. Slight inferior migration of the disc fragment is noted to the left of the midline, indenting the traversing left L5 nerve root. Slight facetal and ligamentum flavum hypertrophy is noted at this level.

Small postero-central protruded discs are noted at the L1-L2, L2-L3 and L3-L4 levels. A posterior disc bulge is seen at the L5-S1 level.

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

Slight facetal hypertrophy is noted at the L5-S1 level.

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A hemangioma with fat content is noted in the L4 vertebral body. Focal fatty marrow changes are noted adjacent to the L2-L3, L4-L5 and L5-S1 intervertebral discs.

Slight anterior wedging of the D12 and L1 vertebral bodies is noted.

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 :

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

IMPRESSION :

1. A posteriorly herniated disc at the L4-L5 level with slight inferior migration of the disc fragment to the left of the midline, indenting the traversing left L5 nerve root with slight facetal and ligamentum flavum hypertrophy at this level.

2. Small postero-central protruded discs at the L1-L2, L2-L3 and L3-L4 levels.

3. Slight facetal hypertrophy at the L5-S1 level.