Date : 00.00.00
Name of the Patient : Abc Xyza Kawlmn / F / 47 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE since 15 days.
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 posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is inferior migration of the disc and which is seen to lie posterior to the L4 vertebral body. A left far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting left L4 nerve root at this level.
Small posterior disc herniations are noted at the L2-L3, L3-L4 and L5-S1 levels. The lumbar intervertebral discs show loss of water content. Schmorls nodes are noted in the dorso-lumbar region.
Facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.
Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4 level.
The pedicles of the lumbar vertebrae appear to be congenitally short in their antero-posterior dimensions.
Type II degenerative changes are noted in the antero-superior aspect of the L4 vertebral body and the S1 vertebra adjacent to the L5-S1 disc.
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 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 :
18.0 mm at L1-L2
15.0 mm at L2-L3
12.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
1. A posterior disc herniation at the L4-L5 level with inferior migration of the disc and which is seen to lie posterior to the L4 vertebral body.
2. Small posterior disc herniations at the L2-L3, L3-L4 and L5-S1 levels.
3. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.
4. A left far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting left L4 nerve root at the L4-L5 level.
5. Facetal hypertrophy at the L4-L5 and L5-S1 levels.
6. Tight spinal canal at the L3-L4 and L4-L5 levels.