Date : 00.00.00
Name of the Patient : Abc Xyz Mlmn / M / 71 yrs.
Referred by : Dr. Abc Xyzhru / Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 1 week.
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 mild forward listhesis of the L4 vertebra over the L5 vertebra.
Posterior disc herniations are seen to indent the thecal sac and narrow both neural foramina at the L4-L5 and L5-S1 levels. Bilateral far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of the exiting L4 and L5 nerve roots at the L4-L5 and L5-S1 levels, respectively. Small posterior peridiscal osteophytes are seen at the L4-L5 level.
A small posterior disc herniation is seen to indent the thecal sac and cause slight left neural foraminal narrowing at the L3-L4 level.
The L4-L5 facet joints show degenerative changes.
There are bilateral far lateral extraforaminal disc bulges at the L2-L3 and L3-L4 levels and on the right side at the L1-L2 level.
Anterior disc herniations are noted in the lumbar region.
The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies 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 D12-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 :
14.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
8.0 mm at L5-S1.
1. Posterior disc herniations with bilateral far lateral (extraforaminal) disc herniations indenting the extraforaminal portion of the exiting L4 and L5 nerve roots at the L4-L5 and L5-S1 levels, respectively.
2. Facetal arthropathy at the L4-L5 level.
3. Canal stenosis at the L4-L5 and L5-S1 levels.
4. A small posterior disc herniation at the L2-L3 level.