Date : 00.00.00
Name of the Patient : Abc Xyz Slmn / F / 60 yrs.
Referred by : Dr. Abc Xyzrankar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 6 months.
H/O fall 1 month ago.
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 lumbar intervertebral discs show loss of water content.
There is slight scoliosis of the lumbar spine with convexity to the right.
There is forward subluxation of the L5 over the S1 vertebra.
There is a posterior and right postero-lateral disc herniation at the L5-S1 level with anterior indentation of the thecal sac and the extraforaminal portion of the right L5 nerve root. The L5-S1 facet joints on the right side show slight degenerative change.
A posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is slight inferior migration of the disc fragment into the right lateral recess of the L5 vertebra with impingement of the right L5 nerve root. There is mild ligamentum flavum hypertrophy and right facetal arthropathy at this level.
A left far lateral disc herniation is seen at the L3-L4 level with mild left neural foraminal narrowing.
A Schmorls node is seen in the anterior aspect of the L1 vertebral body.
Fatty changes are noted in the lower dorsal and lumbar vertebrae suggestive of osteoporosis. Mild anterior wedging of the D11 vertebra is noted.
Anterior disc herniations are seen at the L2-L3, L3-L4 and L4-L5 levels.
Left lateral peridiscal osteophytes are seen over the L1-L2 to L4-L5 levels.
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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
20.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
16.0 mm at L4-L5
14.0 mm at L5-S1.
- 3 - Scan-00009
The MRI features are suggestive of :
1. A posterior and right postero-lateral disc herniation at the L5-S1 level with indentation upon the extraforaminal portion of the right L5 nerve root.
2. A posterior disc herniation at the L4-L5 level with slight inferior migration of the disc fragment in the right lateral recess of the L5 vertebra, mild ligamentum flavum hypertrophy with right facetal arthropathy at this level.