Date : 00.00.00
Name of the Patient : Abc Xyzen Blmn / F / 61 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias.
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 slight forward translation of the L4 over the L5 vertebrae and mild retroplacement of the L5 over the S1 vertebrae. There appears to be spondylolysis of the L4 vertebra bilaterally.
A diffuse posterior disc herniation is seen at the L5-S1 level with posterior peridiscal osteophytes and anterior indentation of the thecal sac. There is resultant bilateral neural foraminal narrowing. There is mild indentation upon the foraminal portion of the exiting L5 nerve roots. Mild facetal hypertrophy is noted at the L5-S1 level.
A posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and mild bilateral neural foraminal narrowing. Small posterior peridiscal osteophytes are also noted at this level. The L4-L5 facet joints show hypertrophic degenerative changes.
Bilateral far lateral (extraforaminal) disc herniations are noted at the L4-L5 and L5-S1 levels.
Small posterior and right far lateral disc bulges are seen at the L2-L3 level. The lumbar intervertebral discs except for the L3-L4 disc show loss of water content.
Type II degenerative changes are seen in the L5 and S1 vertebrae adjacent to the L5-S1 disc.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-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 :
17.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
1. Slight forward translation of the L4 over the L5 and mild retroplacement of the L5 over the S1 vertebra.
2. A diffuse posterior disc herniation at the L5-S1 level with posterior peridiscal osteophytes.
3. A posterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy at the L4-L5 level.
4. Small posterior and right far lateral disc bulges at the L2-L3 level.
5. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 and L5-S1 levels.