Date : 00.00.00
Name of the Patient : Abc Xyzngi Plmn / F / 40 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 2 years.
H/O fall prior to this.
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.
The L2-L3, L3-L4 and L5-S1 intervertebral discs show loss of water content.
The L3 vertebral body is as marked on the film.
There is scoliosis of the lumbar spine with convexity to the left side with clockwise rotation of the lumbar vertebral bodies.
There is a left postero-lateral disc herniation at the L3-L4 level with left neural foraminal narrowing and indentation upon the foraminal portion of the left L3 nerve root.
There is posterior disc herniation at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.
A left far lateral (foraminal and extraforaminal) disc herniation is seen at the L2-L3 level with mild left neural foraminal narrowing and indentation upon the left L2 nerve root.
Small posterior disc bulge is noted at the L4-L5 level.
The L3 vertebral body appears wedged anteriorly without any change is signal intensity.
The upper lumbar facet joints show mild degenerative changes.
Type II degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 disc. Type III degenerative change (sclerosis) is seen in the L5 vertebral body, anteriorly.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S3 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
17.0 mm at L2-L3
18.0 mm at L3-L4
19.0 mm at L4-L5
11.0 mm at L5-S1.
1. A left postero-lateral disc herniation at the L3-L4 level with indentation upon the foraminal portion of the left L3 nerve root.
2. A left far lateral disc herniation at the L2-L3 level with indentation upon the left L2 nerve root.
3. A posterior disc herniation at the L5-S1 level.