Date : 00.00.00
Name of the Patient : Abc XyzGadlmn / M / 37 yrs.
Referred by : Dr. Abc Xyz Hashim.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with numbness 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 loss of normal lumbar lordosis.
The L4-L5 and L5-S1 intervertebral discs show loss of water content.
A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both the neural foramina at the L4-L5 level.
A small posterior disc herniation is noted at the L5-S1 level.
There are far lateral (extraforaminal) disc bulges bilaterally at the L3-L4, L4-L5 and L5-S1 levels. An anterior disc herniation is noted at the L5-S1 level.
Facetal hypertrophy is noted in the lumbar region.
Type I (hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images) and Type II (isointense to fat) degenerative changes are seen within the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
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-L1 level and the thecal sac terminates at the S1-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
15.0 mm at L5-S1.
The MRI features are suggestive of a posterior disc herniation with peridiscal osteophytes at the L4-L5 level.