Date : 00.00.00
Name of the Patient : Abc Xyz Shlmn / F / 40 yrs.
Referred by : Dr. Abc Xyzvade.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 10-12 years which has increased since 2-4 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 a posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints and the ligamentum flavum appear hypertrophied with resultant canal stenosis.
A posterior and left postero-lateral disc herniation is seen at the L5-S1 level with antero-lateral indentation of the thecal sac and bilateral neural foraminal narrowing. The L5-S1 facet joints also show mild degenerative changes.
Small right paracentral disc herniation is seen at the L2-L3 level and a small posterior disc bulge at the L3-L4 level.
There is slight anterior wedging of the L3 and L4 vertebrae without any signal change.
Schmorls nodes are seen in the lumbar region.
- 2 - scan-00003
The lumbar intervertebral discs except for the L1-L2 disc show loss of water content.
The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions.
The lumbar vertebral bodies 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 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
8.0 mm at L2-L3
9.0 mm at L3-L4
6.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation at the L4-L5 level with facetal arthropathy and resultant canal stenosis.
2. A posterior and left postero-lateral disc herniation at the L5-S1 level with mild facetal arthropathy at this level.
3. Small right paracentral disc herniation at the L2-L3 level and a small posterior disc bulge at the L3-L4 level.
4. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions with lumbar canal stenosis.