sb/bv/nl/nl
Name of the Patient : Abc Xyziben Dlmn / F / 64 yrs.
Referred by : Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain to BLE (right more than left) 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 L4-L5 and L5-S1 intervertebral discs and slight loss of water content of the rest of the lumbar intervertebral discs.
There is a small postero-central protruded disc with peridiscal osteophytes at the L5-S1 level, indenting the anterior dural theca anteriorly. A left far lateral disc herniation is also noted at this level with indentation on the foraminal and extraforaminal segment of the left L5 nerve root. Slight facetal and ligamentum flavum hypertrophy is noted at this level.
A small posterior disc bulge with peridiscal osteophytes is noted at the L4-L5 level, with slight facetal and ligamentum flavum hypertrophy at that level.
The lumbar vertebral bodies reveal spotty fatty changes. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L2 level and the thecal sac terminates at the S2 level.
Fat is noted in the filum terminale at the L4 vertebral level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at D12-L1
14.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
12.0 mm at L5-S1.
Note is made of mild spleenomegaly.
IMPRESSION :
1. A small postero-central protruded disc with peridiscal osteophytes at the L5-S1 level, with a left far lateral disc herniation indenting the foraminal and extraforaminal segment of the left L5 nerve root with slight facetal and ligamentum flavum hypertrophy at this level.
2. A small posterior disc bulge with peridiscal osteophytes at the L4-L5 level, with slight facetal and ligamentum flavum hypertrophy at this level.