hs/bv/nl/rg.

Name of the Patient : Abc Xyzlmn / F / 50 yrs.
Referred by : Dr. Abc Xyzhah / Dr. Abc Xyzhta.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain to the LLE 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 :

The lumbar intervertebral discs show loss of water content.

There is slight anterior wedging of the L1 vertebral body with fatty marrow changes within it.

A large left paracentral disc extrusion is seen to indent the thecal sac and narrow the left neural foramen at the L5-S1 level. A disc portion is seen to lie within the left lateral recess of the S1 vertebra with resultant impingement of the traversing left S1 nerve root.

A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.

A small postero-central disc herniation is seen to indent the thecal sac at the L2-L3 level.

There is a posterior disc bulge indenting the thecal sac and narrowing both neural foramina at the L3-L4 level.


Bilateral far lateral disc bulges are noted over the L2-L3 to L5-S1 levels.

The lumbar facet joints show degenerative changes with facetal hypertrophy at the L4-L5 and L5-S1 levels.

A focal area of hyperintensity on all the pulse sequences is seen within the L2 vertebral body on the right side and may represent a hemangioma with fat content. Type II degenerative changes are seen within the lumbar vertebral bodies and within the S1 vertebral body adjacent to the L5-S1 intervertebral disc.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

16.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.

IMPRESSION :

1. A large left paracentral disc extrusion at the L5-S1 level with a disc portion lying within the left lateral recess of the S1 vertebra with resultant impingement of the traversing left S1 nerve root.

2. A small posterior disc herniation at the L4-L5 level.

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

4. Facetal arthropathy in the lumbar region with hypertrophic changes at the L4-L5 and L5-S1 levels.