Date : 00.00.00
Name of the Patient : Abc Xyzhwalmn / M / 66 yrs.
Referred by : Dr. Abc Xyzlal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain to the LLE and RUE since 2-3 months with paresthesias.
C/O wasting of the RLE (thigh region).
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.
The L5 vertebral body is as marked on the film and appears to be sacralized. Please correlate with plain radiographs.
There is a diffuse posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Mild ligamentum flavum hypertrophy is noted at this level.
A postero-central and a left postero-lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and left neural foraminal narrowing.
A small postero-central disc herniation is noted at the L2-L3 level.
Bilateral far lateral (extraforaminal) disc herniations are seen at the L4-L5 level. Bilateral far lateral (extraforaminal) disc bulges are noted at the L2-L3 and L3-L4 levels.
Anterior disc herniations are seen over the L1-L2 to the L4-L5 levels. Anterior and posterior peridiscal osteophytes are noted over these levels. The lumbar intervertebral discs except for the L5-S1 disc show loss of water content.
Severe facetal hypertrophy is noted at the L3-l4 and L4-L5 levels. Mild facetal hypertrophy is noted at the L1-L2 and L2-L3 levels.
There are focal fatty changes in the lumbar vertebrae. Type I/II degenerative changes are seen in the L4 and L5 vertebrae adjacent to the L4-L5 disc.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 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
15.0 mm at L2-L3
14.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
- 3 - Scan-00006
1. A diffuse posterior disc herniation at the L4-L5 level.
2. A postero-central and left postero-lateral disc herniation at the L3-L4 level.
3. A small postero-central disc herniation at the L2-L3 level.
4. Bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level and bilateral far lateral (extraforaminal) disc bulges at the L2-L3 and L3-L4 levels.
5. Severe facetal hypertrophy at the L3-L4 and L4-L5 levels.