Date : 00.00.00
Name of the Patient : Abc Xyzben Plmn / F / 52 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 2 years.
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 reduction in height and loss of water content of the L5-S1 intervertebral disc.
There is a posteriorly herniated disc with posterior peridiscal osteophyte at the L5-S1 level with bilateral neural foraminal narrowing. The L5 and S1 vertebral bodies adjacent to the L5-S1 disc show Type II degenerative changes. Slight inferior migration of the disc is noted posterior to the S1 vertebral body. Far lateral disc bulges are also noted at this level with indentation upon the extraforaminal L5 nerve roots bilaterally.
A minimal posterior disc bulge is seen at the L4-L5 level.
The facet joints at the L4-L5 and L5-S1 levels appear slightly hypertrophied bilaterally.
Anterior peridiscal osteophytes are seen in the lumbar region.
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 L2 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 :
16.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
11.0 mm at L5-S1.
1. Degenerated L5-S1 disc with a posteriorly herniated disc and posterior peridiscal osteophytes, causing bilateral neural foraminal narrowing with inferior migration of the disc posterior to the S1 vertebral body. Far lateral disc bulges are also seen at this level with indentation upon the extraforaminal L5 nerve roots bilaterally.
2. Facetal hypertrophy at the L4-L5 and L5-S1 levels.