Date : 00.00.00
Name of the Patient : Abc Xyzn Plmn / M / 68 yrs.
Referred by : Dr. Abc XyzBR>
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 3 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.
There is a evidence of a posterior disc herniation with peridiscal osteophytes, more to the right of the midline and indenting the thecal sac at the L4-L5 level. There is bilateral neural foraminal narrowing and impingement of the exiting L4 nerve roots bilaterally (right more than left) at this level. There is probable inflammation of the exiting right L4 nerve root.
The L4-L5 facet joints show hypertrophic degenerative changes. Also seen is ligamentum flavum hypertrophy with a resultant tight canal at this level.
A postero-central disc protrusion is seen to indent the thecal sac at the L5-S1 level.
There is a right far lateral (extraforaminal) disc herniation at the L4-L5 level. Also seen are far lateral (extraforaminal) disc bulges bilaterally over the D12-L1 to L3-L4 levels and on the left side at the L4-L5 level.
The lumbar intervertebral discs show loss of water content. The superior cortical endplate of the L5 vertebra is irregularly defined and shows evidence of Type I degenerative changes.
There appears to be conjoint nerve roots on the left side at the S1 vertebral level.
The rest of 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-S2 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
16.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
14.0 mm at L5-S1.
- 3 - Scan-00007
1. A posterior disc herniation with peridiscal osteophytes, more to the right of the midline with impingement of the exiting L4 nerve roots bilaterally, right more than left at the L4-L5 level. There is probable inflammation of the exiting right L4 nerve root.
2. Hypertrophic facetal hypertrophy and ligamentum flavum hypertrophy with canal stenosis at the L4-L5 level.
3. A right far lateral (extraforaminal) disc herniation at the L4-L5 level.
4. A postero-central disc protrusion at the L5-S1 level.