Date : 00.00.00
Name of the Patient : Abc Xyzn Klmn / M / 53 yrs.
Referred by : Dr. Abc Xyzdy / Dr. Abc Xyznna. Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 20-25 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 is probable sacralization of the L5 vertebra which is as marked on the film (Kindly correlate with plain radiographs).
There is a posterior and a left postero-lateral disc herniation at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is indentation upon the extraforaminal portion of the left L3 nerve root.
A posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L3-L4 and L4-L5 intervertebral discs show loss of water content.
The lumbar facet joints show degenerative changes.
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 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
11.0 mm at L4-L5
13.0 mm at L5-S1.
The MRI features are suggestive of :
1. Probable sacralization of the L5 vertebra.
2. A posterior and a left postero-lateral disc herniation at the L3-L4 level with indentation upon the extraforaminal portion of the left L3 nerve root.
3. A posterior disc herniation at the L4-L5 level.
4. Facetal arthropathy in the lumbar region.