Date : 00.00.00
Name of the Patient : Abc Xyzbi Shlmn / F / 48 yrs.
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain, radiating to BLE (RLE more than the LLE) since 6 months with paresthesias.
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 loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is a posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing. A sequestered disc fragment is noted in the right lateral recess of the L5 vertebra, indenting the traversing right L5 nerve root.
A small posterior disc bulge is noted at the L5-S1 level.
A small, right postero-lateral disc herniation is noted at the L3-L4 level with resultant mild neural foraminal narrowing.
Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.
Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4, L4-L5 and L5-S1 levels.
Hemangiomas with fat content are noted in the L2 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.
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 :
15.0 mm at L1-L2
14.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.
1. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level with a sequestered disc fragment in the right lateral recess of the L5 vertebra, indenting the traversing right L5 nerve root.
2. A small, right postero-lateral herniated disc at the L3-L4 level.
3. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels.
4. Canal stenosis at the L4-L5 level.