Date : 00.00.00
Name of the Patient : Abc XyzT. lmn / M / 48 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to RLE with numbness and difficulty in walking.
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 probable partial sacralization of the L5 vertebra on the left (Kindly correlate with plain radiographs).
There is an anterior and diffuse posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. A free fragment is seen in the right lateral recess of the L5 vertebra with impingement of the right L5 nerve root.
The L4-L5 facet joint on the left side shows degenerative changes.
A small postero-central disc herniation is noted at the L3-L4 level with anterior indentation of the thecal sac. The L3-L4 and L4-L5 intervertebral discs show loss of water content. Posterior peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels.
There is ligamentum flavum hypertrophy at the L4-L5 and L5 levels.
Type I/II degenerative changes are noted in the L4 and L5 vertebrae adjacent to the L4-L5 intervertebral disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints appear slightly hypertrophied. 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 :
18.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
15.0 mm at L5-S1.
The MRI features are suggestive of :
1. An anterior and diffuse posterior disc herniation at the L4-L5 level with a free fragment seen in the right lateral recess of the L5 vertebra impinging the right L5 nerve root with facetal arthropathy on the left side at this level.
2. A small postero-central disc herniation at the L3-L4 level.
3. Slight facetal hypertrophy of the rest of the lumbar facet joints.