Date : 00.00.00
Name of the Patient : Abc XyzBalmn / F / 44 yrs.
Referred by : Dr. Abc Xyzorude.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 1 month.
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 slight retrolisthesis of the L5 vertebra over the S1 vertebra.
There is a posterior disc extrusion at the L5-S1 level with anterior indentation of the thecal sac. There is inferior migration of the disc with indentation upon the traversing S1 nerve roots (left more than right). The L5-S1 facet joints show mild degenerative change with slight effusion on the right side. There is bilateral neural foraminal narrowing at this level.
Bilateral far lateral (extraforaminal) disc herniations are seen at the L5-S1 level.
A postero-central disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac. The L4-L5 facet joints also show mild degenerative change.
Anterior disc herniations are noted in the L1-L2, L2-L3, L3-L4 and L5-S1 levels. The L4-L5 and L5-S1 intervertebral discs show loss of water content.
Type II degenerative changes are seen in the L5 and S1 vertebrae adjacent to the L5-S1 intervertebral disc and at the antero-superior aspect of the L3 and L4 vertebral bodies.
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.
A cortical renal cyst is noted on the left side.
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 :
14.0 mm at L1-L2
14.0 mm at L2-L3
14.0 mm at L3-L4
9.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Slight retrolisthesis of the L5 vertebra over the S1 vertebra.
- 3 - Scan-00009
2. A posterior disc extrusion at the L5-S1 level with inferior migration of the disc and indentation on the traversing S1 nerve roots (left more than right) with mild facetal arthropathy at this level.
3. A postero-central disc herniation at the L4-L5 level with
mild facetal arthropathy at this level.
4. Bilateral far lateral (extraforaminal) disc herniations at the L5-S1 level.
5. Canal stenosis at the L5-S1 level and a tight canal at the L4-L5 level.