Date : 00.00.00
Name of the Patient : Abc Xyz lmn / F / 40 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 6 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 right paracentral disc herniation is seen to indent the traversing right S1 nerve root at the L5-S1 level.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina 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.
Slight facetal and ligamentum flavum hypertrophy is noted at the L4-L5 and L5-S1 levels. The intervertebral discs at these levels show loss of water content.
Focal fatty change is seen in the antero-superior portion of the L4 vertebra and a hemangioma in the S1 vertebral body.
The rest of 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-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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
8.0 mm at L4-L5
9.0 mm at L5-S1.
1. A posterior disc herniation with canal stenosis 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.
2. A right paracentral disc herniation indenting the traversing right S1 nerve root at the L5-S1 level.
3. Slight facetal and ligamentum flavum hypertrophy at the L4-L5 and L5-S1 levels.