Date : 00.00.00
Name of the Patient : Abc Xyz Shlmn / M / 57 yrs.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain in BLE (left more than right) with paresthesias since 2 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 mild retrolisthesis of the L5 vertebra over the S1 vertebra.
There is a large posterior disc extrusion compressing upon the thecal sac and narrowing both the neural foramina at the L4-L5 level. A disc portion is seen to lie within the spinal canal at the L5 vertebral level with resultant impingement of the traversing left L5 nerve root. Also seen is compression and displacement of the thecal sac to the right side at this level.
A small postero-central disc herniation with peridiscal osteophytes is noted at the L5-S1 level.
Anterior disc herniations are noted at the L4-L5 and L5-S1 levels. The intervertebral discs at these levels show loss of water content. Type II degenerative changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
4.0 mm at L4-L5
8.0 mm at L5-S1.
Screening of the hip joints reveal no feature of note.
1. A large posterior disc extrusion compressing upon the thecal sac and severe canal stenosis at the L4-L5 level with a disc portion lying within the spinal canal at the L5 vertebral level with resultant impingement of the traversing left L5 nerve root.
2. A small postero-central disc herniation with peridiscal osteophytes at the L5-S1 level.