Date : 00.00.00
Name of the Patient : Abc Xyz Chlmn / M / 55 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with paresthesias since 15 days.
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.
FEW IMAGES SHOW PATIENT MOTION.
There is loss of normal lumbar lordosis. The L1-L2 to L4-L5 intervertebral discs show loss of water content.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. There is indentation upon the traversing L5 nerve roots bilaterally. Bilateral far lateral (extraforminal) disc herniations are seen at this level.
The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes.
Left paracentral and left postero-lateral disc herniations are seen to indent the thecal sac and narrow the left neural foramen, respectively at the L2-L3 level.
A posterior disc bulge is seen at the L3-L4 level. Bilateral far lateral (extraforaminal) disc bulges are seen at the L3-L4 level and on the left side at the L5-S1 level.
The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions.
The L1-L2 and L2-L3 facet joints show mild degenerative changes.
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 D12 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 :
14.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.
- 3 - Scan-00003
The MRI features are suggestive of :
1. A posterior disc herniation with hypertrophic facetal arthropathy and canal stenosis at the L4-L5 level.
2. Left paracentral and left postero-lateral disc herniations at the L2-L3 level.
3. A posterior disc bulge with hypertrophic facetal arthropathy at the L3-L4 level.
4. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.
5. A tight canal at the L2-L3 and L3-L4 levels.