Date : 00.00.00
Name of the Patient : Abc Xyzlmn / F / 25 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the LLE with paresthesias.
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 appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
There is a large postero-central disc extrusion with a posterior peridiscal osteophytes compressing upon the thecal sac at the L4-L5 level. A disc portion is seen to lie within the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root.
There is mild ligamentum flavum and facetal hypertrophy at the L4-L5 level. Mild facetal hypertrophy is also seen at the L3-L4 level.
Bilateral far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting L4 nerve roots bilaterally (left more than right) at the L4-L5 level.
Type II degenerative changes are seen within the L5 vertebral body adjacent to the L4-L5 intervertebral disc.
The L4-L5 intervertebral disc shows loss of water content.
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 :
22.0 mm at L1-L2
20.0 mm at L2-L3
19.0 mm at L3-L4
8.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. Probable sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A large postero-central disc extrusion with a posterior peridiscal osteophyte with resultant canal stenosis at the L4-L5 level. A disc portion is seen to lie within the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root.
3. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.