Date : 00.00.00
Name of the Patient : Abc Xyzm Jalmn / M / 40 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 5 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 a posterior disc herniation indenting the thecal sac and narrowing both neural foramina at the L4-L5 level. A disc portion is seen to lie within the left lateral recess of the L5 vertebra with resultant impingement of the traversing left L5 nerve root.
Bilateral far lateral disc herniations are seen to indent the extraforaminal portion of the exiting L4 nerve roots at the L4-L5 level.
Large right postero-lateral and right far lateral disc herniations are seen to narrow the right neural foramen and indent the exiting right L3 nerve root at the L3-L4 level. A left far lateral disc bulge is noted at this level.
The L5-S1 facet joints show degenerative changes. A mild posterior disc bulge is noted at this level.
- 2 - scan-00009
There is facetal hypertrophy over the L1-L2 to L4-L5 levels.
The L4-L5 intervertebral disc shows loss of water content.
The L3-L4 intervertebral disc shows mild loss of water content.
Type I/II degenerative changes are noted within the L4 and L5 vertebral bodies adjacent to the L3-L4 and L4-L5 intervertebral discs.
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 L1-L2 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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
16.0 mm at L5-S1.
- 3 - Scan-00009
1. A posterior disc herniation with a disc portion seen to lie within the left lateral recess of the L5 vertebra with resultant impingement of the traversing left L5 nerve root.
2. Large right postero-lateral and right far lateral disc herniations indenting the exiting right L3 nerve root at the L3-L4 level.
3. Bilateral far lateral disc herniatons indenting the extraforaminal portion of the exiting L4 nerve roots at the L4-L5 level.