Date : 00.00.00
Name of the Patient : Abc Xyzshna Sahasrabulmn / M / 67 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the right hip since 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.
There is a large posterior disc herniation with peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina at the L4-L5 level. A right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L4 nerve root at this level. The L4-L5 facet joints show degenerative changes.
A postero-central disc protrusion is noted at the L5-S1 level. Left postero-lateral and left far lateral disc herniations are seen to narrow the left neural foramen indenting the left exiting L5 nerve root at this level. Also seen is a right far lateral (extraforaminal) disc bulge at this level.
A posterior disc bulge is seen to indent the thecal sac and cause mild neural foraminal narrowing bilaterally at the L3-L4 level. Anterior disc herniations are noted at the L2-L3, L3-L4 and L4-L5 levels.
Type I/II degenerative changes are noted within the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc. The lumbar vertebral bodies show areas of fatty replacement of normal marrow which may suggest osteoporosis. The lumbar intervertebral discs show loss of water content.
The remaining 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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large posterior disc herniation with peridiscal osteophytes and facetal arthropathy with a tight canal at the L4-L5 level.
2. A postero-central disc protrusion at the L5-S1 level.
3. Left postero-lateral and left far lateral disc herniations indenting the exiting left L5 nerve root at the L5-S1 level.
4. A posterior disc bulge at the L3-L4 level.