Date : 00.00.00
Name of the Patient : Abc Xyzee Jlmn / F / 58 yrs.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 2 1/2 years.
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 scoliosis of the lumbar spine with convexity to the left side.
There is slight retrolisthesis of the L2 over the L3 and the L4 over the L5 vertebral body.
The lumbar intervertebral discs show loss of water content.
A large postero-central disc extrusion is seen at the L4-L5 level with anterior compression of the thecal sac and canal stenosis. There is inferior migration of the disc fragment which is seen to lie posterior to the L5 vertebral body with compression upon the thecal sac and indentation upon the left L5 nerve root. A left far lateral disc herniation is also noted at this level.
Posterior disc herniation and a left far lateral disc bulge is seen at the L3-L4 level with peridiscal osteophytes.
A posterior and left far lateral disc bulge is seen at the L5-S1 level.
Postero-central disc herniations are noted at the L1-L2 and L2-L3 levels with posterior peridiscal osteophytes.
Lateral peridiscal osteophytes are seen at the L2-L3 level on the right side.
Type II degenerative changes are seen in the L5 vertebral body adjacent to the L4-L5 intervertebral disc.
The lower lumbar facet joints show mild degenerative changes.
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 L2 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 :
14.0 mm at L1-L2
12.0 mm at L2-L3
11.0 mm at L3-L4
9.0 mm at L4-L5
10.0 mm at L5-S1.
- 3 - Scan-00005
1. Scoliosis of the spine with convexity to the left side.
2. Slight retrolisthesis of the L2 over the L3 and the L4 over the L5 vertebral body.
3. A large postero-central disc extrusion at the L4-L5 level
with inferior migration of the disc fragment which is seen to lie posterior to the L5 vertebral body and indentation upon the left L5 nerve root with canal stenosis.
4. A posterior disc herniation at the L3-L4 level.