w Date : 00.00.00
Name of the Patient : Abc Xyz C. Malmn / F / 55 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias.
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 L1 vertebra appears to be as marked on the film. Please correlate with plain radiographs.
A postero-central disc extrusion is seen to indent the thecal sac at the L4-L5 level. A disc portion is seen to lie within the left lateral recess of L5 vertebra with resultant impingement of the traversing left L5 nerve root.
A postero-central disc herniation is seen to indent the thecal sac at the L2-L3 level.
Bilateral far lateral (extraforaminal) disc herniations are noted at the L5-S1 level with resultant indentation upon the extraforaminal portion of the exiting right L5 nerve root at this level.
The right L5-S1 facet joint shows hypertrophic degenerative changes. Mild facetal hypertrophy is also noted on the left side at this level. The L4-L5 facet joints bilaterally and the left facet joint at the L3-L4 level show mild degenerative changes.
The lumbar intervertebral discs show loss of water content. The paraspinal muscles in the lower lumbar region show slight atrophy.
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 S2 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
11.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
13.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc extrusion at the L4-L5 level with a disc portion lying within the left lateral recess of L5 vertebra with resultant impingement of the traversing left L5 nerve root.
- 3 - Scan-00000
2. A postero-central disc herniation at the L2-L3 level.
3. Bilateral far lateral (extraforaminal) disc herniations at the L5-S1 level with resultant indentation upon the extraforaminal portion of the exiting right L5 nerve root at this level.
4. Hypertrophic facetal arthropathy on the right side at the L5-S1 level.