Date : 00.00.00
Name of the Patient : Abc Xyz.S. lmn / M / 33 yrs.
Referred by : Dr. Abc Xyzosale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with tingling since 6-7 months.
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 loss of normal lumbar lordosis. The L4-L5 and L5-S1 intervertebral discs show loss of water content.
A large posterior disc extrusion is seen to indent the thecal sac and narrow both neural foramina (left more than right) at the L5-S1 level. There is impingement of the right exiting L5 nerve root at this level. A disc portion is seen within the anterior epidural space at the S1 vertebral level with indentation upon both the traversing S1 nerve roots.
A large posterior disc extrusion is seen to compress the thecal sac and narrow both neural foramina at the L4-L5 level. A disc portion is seen to lie within the right lateral recess of the L5 vertebra with impingement of the right L5 nerve root.
The L4-L5 and L5-S1 facet joints show hypertrophic degenerative changes. Ligamentum flavum hypertrophy is seen at the L5 level. Posterior peridiscal osteophytes are also noted at these levels.
- 2 - scan-00000
The rest of the lumbar facet joints show mild degenerative changes.
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 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 :
18.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.
The cervico-dorsal spine was screened with the help of 4 mm thick T1 Weighted sagittal images which does not reveal any diagnostic feature of note.
The MRI features are suggestive of :
1. Large posterior disc extrusions at the L4-L5 and L5-S1 levels with canal stenosis.
2. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.