Date : 00.00.00
Name of the Patient : Abc Xyzan Jlmn / M / 73 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain in the RLE with tingling since 8 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 sacralization of the L5 vertebra and it is as marked on the film.
There is loss of water content of all the lumbar intervertebral discs.
There is a postero-central and right postero-lateral disc herniation at the L4-L5 level with right neural foraminal narrowing. A sequestered disc fragment is noted in the right lateral recess of the L5 vertebra and indenting the traversing right L5 nerve root. Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels. The L4-L5 facet joints show hypertrophic degenerative changes.
A small posterior disc bulge is noted at the L3-L4 level. A small right postero-lateral disc herniation is seen to narrow the right neural foramen at the L3-L4 level.
Right far lateral (exrtraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting right L3 and L4 nerve roots at the L3-L4 and L4-L5 levels, respectively.
The remaining lumbar vertebral bodies show fatty marrow changes. The 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. A postero-central and right postero-lateral disc herniation at the L4-L5 level with a sequestered disc fragment in the right lateral recess of the L5 vertebra and indenting the traversing right L5 nerve root.
3. Ligamentum flavum hypertrophy at the L4-L5 and L5 levels and hypertrophic facetal arthropathy at the L4-L5 level.
4. Right far lateral (extraforaminal) disc herniations indenting the extraforaminal portion of the exiting right L3 and L4 nerve roots at the L3-L4 and L4-L5 levels respectively.
5. A small right postero-lateral disc herniation at the L3-L4 level.