Date : 00.00.00
Name of the Patient : Abc Xyz. Ghlmn / M / 59 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 3-4 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 mild forward listhesis of the L4 vertebra over the L5 vertebra.
A large posterior disc extrusion is seen to compress the thecal sac and narrow both neural foramina at the L4-L5 level. The L4-L5 facet joints show hypertrophic degenerative changes with resultant canal stenosis. Also seen are bilateral far lateral (extraforaminal) disc herniations at this level.
A postero-central disc herniation is seen to indent the thecal sac at the L3-L4 level. A small postero-central disc herniation is noted at the L5-S1 level.
Right far lateral (extraforaminal) disc herniations are noted at the L3-L4 and L1-L2 levels. A right foraminal disc bulge is noted at the L2-L3 level.
The rest of the lumbar facet joints show mild degenerative changes.
Type II degenerative changes are noted at the L4 and L5 vertebral bodies adjacent to the L4-L5 disc and along the antero-superior aspect of the L2 vertebral body. The L1-L2, L2-L3 and L4-L5 intervertebral discs show loss of water content.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
11.0 mm at L3-L4
5.0 mm at L4-L5
9.0 mm at L5-S1.
1. Mild forward listhesis of the L4 vertebra over the L5 vertebra.
2. A large posterior disc extrusion and hypertrophic facetal arthropathy with severe canal stenosis at the L4-L5 level.
- 3 - Scan-00001
3. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.
4. A postero-central disc herniation at the L3-L4 level.