Date : 00.00.00
Name of the Patient : Abc Xyzang lmn / M / 53 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache 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.
6 mm thick T1 Weighted coronal images.
5 mm thick STIR coronal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
There is a posterior disc herniation at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L5-S1 facet joints show slight degenerative changes with resultant canal stenosis at this level. Bilateral far lateral (extraforaminal) disc herniations are noted at this level.
A large postero-central and bilateral postero-lateral disc herniations are seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Mild facetal arthropathy is noted at this level with resultant canal stenosis. Bilateral far lateral (extraforaminal) disc bulges are seen at this level.
Small posterior disc bulges are seen at the L2-L3 and L3-L4 levels. A right postero-lateral disc protrusion is noted at the L2-L3 level with right neural foraminal narrowing.
The lumbar intervertebral discs show loss of water content.
A large well circumscribed lesion is seen along the right S1 nerve sheath which measures approximately 2.0 x 1.8 cms and which is seen to expand the right neural foramen at that level. This lesion is slightly hyperintense to CSF on the T1 Weighted images and turns more hyperintense on the T2 Weighted images.
The lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
11.0 mm at L1-L2
10.0 mm at L2-L3
10.0 mm at L3-L4
8.0 mm at L4-L5
10.0 mm at L5-S1.
1. A posterior disc herniation at the L5-S1 level with degenerative changes of the L5-S1 facet joints with resultant canal stenosis.
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2. A large postero-central and bilateral postero-lateral disc herniations at the L4-L5 level with mild facetal arthropathy at this level with resultant canal stenosis.
3. Small posterior disc bulges at the L2-L3 and L3-L4 levels.
4. A right postero-lateral disc protrusion at the L2-L3 level.
5. A Tarlovs/perineural cyst along the right S1 nerve sheath in the right S1-S2 neural foramen.