Date : 00.00.00
Name of the Patient : Abc Xyz Hasan Tlmn / F / 46 yrs.
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Alleged H/O fall 2 months ago with backache.
C/O weakness of BLE with bladder/bowel involvement since 10 days.
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 appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
There is loss of normal lumbar lordosis. Also seen is mild retrolisthesis of the L4 vertebra over the L5 vertebra. The lumbar intervertebral discs show mild loss of water content.
A large postero-central disc extrusion is seen to compress the thecal sac at the L3-L4 level.
A posterior disc herniation with peridiscal osteophyte is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. Areas of hypointensity on the T1 Weighted images which remain predominantly hypointense on the T2 Weighted images are seen within the antero-superior aspect of the L5 vertebral body and may represent Type III degenerative changes.
Bilateral far lateral (extraforaminal) disc bulges are seen at the L1-L2, L2-L3 and L4-L5 levels. An anterior disc herniation with peridiscal osteophytes is noted at the L4-L5 level.
The rest of the lumbar vertebral bodies 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 :
14.0 mm at L1-L2
12.0 mm at L2-L3
4.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A large postero-central disc extrusion with severe canal stenosis at the L3-L4 level.
3. A posterior disc herniation with peridiscal osteophyte with a tight canal at the L4-L5 level.