Date : 00.00.00
Name of the Patient : Abc Xyz S. Plmn / M / 38 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O paresthesias in the LLE and pain in the left paraspinal region since 2 months.
C/O occasional radiation of pain to the RLE.
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 appears to be sacralization of the L5 vertebra and the L4 vertebra is as marked on the film. Please correlate with plain radiographs.
A posterior disc herniation with peridiscal osteophytes, more to the left of the midline is seen to indent the thecal sac and traversing left L5 nerve root at the L4-L5 level. Mild bilateral neural foraminal narrowing is noted at this level.
The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes.
A mild posterior disc bulge is seen at the L3-L4 level.
Type II degenerative changes are noted within the inferior aspect of the L4 vertebral body adjacent to the L4-L5 intervertebral disc. The L4-L5 intervertebral disc shows loss of water content.
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 D12 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 :
19.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A posterior disc herniation with peridiscal osteophytes, more to the left of the midline indenting the traversing left L5 nerve root at the L4-L5 level.
3. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels.