Date : 00.00.00
Name of the Patient : Abc Xyz DSlmn / M / 54 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE 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 a postero-central disc herniation indenting the thecal sac at the L5-S1 level. A right far lateral (extraforaminal) disc bulge is seen to indent the extraforaminal portion of the exiting right L5 nerve root at this level.
A postero-central disc herniation, more to the right of the midline is seen at the L4-L5 level with mild indentation upon the thecal sac. A disc portion is seen to lie within the right lateral recess of the L5 vertebra with impingement of the traversing right L5 nerve root.
Postero-central disc protrusions are seen at the D12-L1, L1-L2, L2-L3 and L3-L4 levels.
Bilateral far lateral (extraforaminal) disc bulges are seen at the L2-L3, L3-L4 and L4-L5 levels.
The lumbar intervertebral discs show loss of water content. The lumbar facet joints show mild degenerative changes.
The lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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 :
16.0 mm at L1-L2
14.0 mm at L2-L3
14.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc herniation at the L5-S1 level.
2. A postero-central disc herniation at the L4-L5 level with a disc portion within the right lateral recess of the L5 vertebra with impingement of the traversing right L5 nerve root.
3. Postero-central disc protrusions at the D12-L1, L1-L2, L2-L3 and L3-L4 levels.
4. Mild facetal arthropathy in the lumbar region.
5. Far lateral (extraforaminal) disc bulges bilaterally at the L2-L3, L3-L4 and L4-L5 levels and on the right side at the L5-S1 level.