Date : 00.00.00
Name of the Patient : Abc Xyz Plmn / M / 39 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with tingling since 4 months.
H/O lifting heavy weights.
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 large, posterior disc herniation at the L3-L4 level with a posterior peridiscal osteophyte. There is resultant compression upon the thecal sac and mild neural foraminal narrowing bilaterally. There is mild superior migration of the disc fragment. The L3-L4 intervertebral disc shows loss of water content.
A postero-central and left postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. This intervertebral disc shows mild loss of water content. The L4-L5 facet joints show mild degenerative changes.
Schmorls nodes are noted at the L3-L4 level. An anterior disc herniations with peridiscal osteophytes is seen at this level.
There is a suggestion of a hemangioma with fatty content in the D11 vertebral body.
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 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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
8.0 mm at L3-L4
11.0 mm at L4-L5
15.0 mm at L5-S1.
1. A large, posterior disc herniation with a posterior peridiscal osteophyte at the L3-L4 level with severe canal stenosis.
2. A postero-central and left postero-lateral disc herniation at the L4-L5 level with a tight canal.