Date : 00.00.00
Name of the Patient : Abc Xyzgh Jalmn / M / 34 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 15 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 partial sacralization of the L5 vertebra.
There is loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
A small posterior disc bulge is noted at the L5-S1 level.
A posteriorly herniated disc is seen at the L4-L5 level with inferior migration of the disc fragment to the right of the midline, indenting the traversing right L5 nerve root. There is bilateral neural foraminal narrowing. Mild ligamentum flavum hypertrophy is noted at this level.
A postero-central disc herniation with peridiscal osteophyte is noted at the L3-L4 level, with thecal sac compression.
Facetal hypertrophy is noted in the lumbar region. The pedicles of the lower lumbar vertebrae appear congenitally short in their antero-posterior dimensions, with a resultant tight lumbar canal at the L3-L4 and L4-L5 levels.
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
12.0 mm at L4-L5
8.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. A posteriorly herniated disc at the L4-L5 level with slight inferior migration of the disc fragment to the right of the midline, indenting the traversing right L5 nerve root.
3. A postero-central disc herniation with peridiscal osteophyte at the L3-L4 level.
4. Facetal hypertrophy in the lumbar region.
5. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions, with a resultant tight lumbar canal at the L3-L4 and L4-L5 levels.