Date : 00.00.00
Name of the Patient : Abc Xyzi N. Shlmn / F / 66 yrs.
Referred by : Dr. Abc Xyzlwalkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 1 1/2 months.
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.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. Bilateral far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting L4 nerve roots bilaterally at this level. The L4-L5 facet joints show hypertrophic degenerative changes.
A postero-central disc herniation is seen to indent the thecal sac at the L3-L4 level. A left postero-lateral (foraminal) disc herniation is seen to narrow the left neural foramen and indent the exiting left L3 nerve root at the L3-L4 level. Bilateral far lateral (extraforaminal) disc bulges are noted at this level.
There is a posterior disc bulge at the L2-L3 level. A left postero-lateral (foraminal) disc protrusion is seen to indent the exiting left L2 nerve root at this level.
There is a small postero-central disc herniation indenting the thecal sac at the L1-L2 level.
The lumbar intervertebral discs show loss of water content.
Anterior disc herniations are seen over the L1-L2 to L4-L5 levels.
Note is made of a left renal cyst.
The lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and 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 :
12.0 mm at L1-L2
15.0 mm at L2-L3
12.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.
- 3 - Scan-00005
1. A posterior disc herniation and hypertrophic facetal arthropathy with a tight canal at the L4-L5 level.
2. A postero-central disc herniation and a left postero-lateral (foraminal) disc herniation indenting the exiting left L3 nerve root at the L3-L4 level.
3. A posterior disc bulge at the L2-L3 level.
4. A small postero-central disc herniation at the L1-L2 level.
5. A left postero-lateral (foraminal) disc protrusion indenting the exiting left L2 nerve root at the L2-L3 level.