Date : 00.00.00
Name of the Patient : Abc Xyzi Glmn / M / 35 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 1 year.
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.
The L4-L5 and L5-S1 intervertebral discs show loss of water content.
There is a posterior disc herniation at the L4-L5 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing, (left more than the right) and indentation upon the left L4 nerve root. The L4-L5 facet joint on the left side shows degenerative change. Posterior peridiscal osteophytes are also noted at this level with canal stenosis. An anterior disc herniation is also seen at this level.
There is a left postero-lateral disc herniation at the L5-S1 level with left neural foraminal narrowing and indentation upon the foraminal/extraforaminal left L5 nerve root.
The pedicles of the lower lumbar vertebrae are congenitally short in their antero-posterior dimensions.
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 L1-L2 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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
7.0 mm at L4-L5
9.0 mm at L5-S1.
1. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing, (left more than the right) with indentation upon the left L4 nerve root with canal stenosis.
2. A left postero-lateral disc herniation at the L5-S1 level.
3. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions.