Date : 00.00.00
Name of the Patient : Abc Xyz lmn / F / 60 yrs.
Referred by : Dr. Abc Xyzra.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with tingling in the RLE since 5-6 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.
There is forward translation of the L3 over the L4 and L4 over the L5 vertebra (kindly correlate with plain radiographs to R/o spondylolysis).
There is a posterior and left far lateral disc herniation at the L5-S1 level with anterior indentation of the thecal sac and indentation on the extraforaminal segment of the left L5 nerve root. The L5-S1 facet joint on the left side shows slight degenerative changes.
A large pseudoposterior disc herniation is seen at the L4-L5 level with anterior compression of the thecal sac and resultant canal stenosis. Hypertrophic facetal arthropathy is also noted at this level. The right L4 nerve root is impinged in the right neural foramen at the L4-L5 level.
Posterior and a left far lateral disc herniation is noted at the L3-L4 level with anterior indentation of the thecal sac and mild left neural foraminal narrowing. The L3-L4 facet joints also show mild degenerative change.
Small posterior disc bulges with peridiscal osteophytes are seen at the L1-L2 and L2-L3 levels. Anterior disc herniations are noted at the L3-L4, L4-L5 and L5-S1 levels. The lumbar intervertebral discs show loss of water content. The D11-D12, L1-L2, L3-L4, L4-L5 and L5-S1 intervertebral discs are reduced in height.
Type II degenerative change is seen in the L5 and S1 vertebral bodies adjacent to the L5-S1 disc. Similar change is noted in the antero-superior portion of the L2 vertebral body as well as the D11 and D12 vertebrae.
A hemangioma with fat content is seen in the L3 vertebral body.
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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
16.0 mm at L2-L3
9.0 mm at L3-L4
16.0 mm at L4-L5
9.0 mm at L5-S1.
- 3 - Scan-00002
1. Forward translation of the L3 over the L4 and L4 over the L5 vertebra.
2. A posterior and left far lateral disc herniation at the L5-S1 level with indentation upon the extraforaminal portion of the left L5 nerve root and degenerative changes of the L5-S1 facet joint on the left side.
3. A large pseudoposterior disc herniation at the L4-L5 level with resultant canal stenosis and hypertrophic facetal arthropathy at this level. The right L4 nerve root is impinged in the right neural foramen at the L4-L5 level.
4. Posterior and a left far lateral disc herniation at the L3-L4 level with mild degenerative changes of the L3-L4 facet joints.
5. Small posterior disc bulges with peridiscal osteophytes at the L1-L2 and L2-L3 levels.