Date : 00.00.00
Name of the Patient : Abc Xyzla Nagbhulmn / F / 39 yrs.
Referred by : Dr. Abc XyzV. Shah / Dr. Abc XyzVani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the RLE since 2 years.
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.
There is mild retrolisthesis of the L4 vertebra over the L5 vertebra. The L3-L4 and L4-L5 intervertebral discs show loss of water content.
A small posterior disc bulge is noted at the L5-S1 level. This intervertebral disc shows slight loss of water content. The L5-S1 facet joints shows severe hypertrophic degenerative changes.
A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. Left postero-lateral and left far lateral disc herniations are seen to narrow the left neural foramen and indent the exiting left L4 nerve root at the L4-L5 level.
A posterior disc bulge is seen to indent the thecal sac at the L3-L4 level. A left postero-lateral disc protrusion is seen to narrow the left neural foramen at this level.
Facetal hypertrophy is noted at the L3-L4 and L4-L5 levels.
The lumbar vertebral bodies and the remaining intervertebral discs show normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the D12-L1 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
12.0 mm at L3-L4
9.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. A small posterior disc bulge and severe hypertrophic facetal arthropathy with canal stenosis at the L5-S1 level.
2. A posterior disc herniation with canal stenosis at the L4-L5 level.
3. Left postero-lateral and left far lateral disc herniations at the L4-L5 level.
4. Facetal hypertrophy at the L3-L4 and L4-L5 levels.