Date : 00.00.00
Name of the Patient : Abc Xyz Belvalmn / M / 62 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with inability to walk since 15 days.
H/O lifting heavy weight.
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 on the left side. Scoliosis of the lumbar spine with convexity to the left is noted.
A posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac. Bilateral far lateral disc bulges are also noted at these levels with bilateral neural foraminal narrowing and indentation upon the extraforaminal portion of the L4 nerve roots. The L4-L5 facet joints bilaterally, right more than left show degenerative changes.
A postero-central and a right postero-lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, right more than left. The L3-L4 facet joint on the right side shows hypertrophic facetal arthropathy with resultant lateral recess stenosis. There is inferior migration of the disc which is seen to lie posterior to the L4 vertebral body with mild indentation upon the L4 nerve roots.
- 2 - scan-00001
Small, posterior disc bulges are seen at the L1-L2 and L2-L3 levels with anterior indentation of the thecal sac. Small right postero-lateral disc herniation is noted at the L2-L3 level, with slight inferior migration of the disc fragment. The facet joints at these levels also show slight degenerative changes.
Posterior peridiscal osteophytes are noted in the lumbar region. Small anterior disc herniations are seen in the lower lumbar region with anterior peridiscal osteophytes. The L4-L5 intervertebral disc is reduced in height.
Type II degenerative changes are seen in the L4 and L5 vertebrae adjacent to the L4-L5 intervertebral disc.
The lower dorsal region show small posterior disc bulges.
The visualized lower dorsal spinal cord shows normal signal intensity.
The rest of the lumbar vertebral bodies and the 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 D12-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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
15.0 mm at L4-L5
10.0 mm at L5-S1.
- 3 - scan-00001
The MRI features are suggestive of :
1. Partial sacralization of the L5 vertebra on the left side with scoliosis of the lumbar spine and convexity to the left.
2. A posterior disc herniation at the L4-L5 level with bilateral far lateral disc bulges at these levels indenting the extraforaminal portion of the L4 nerve roots. There is facetal arthropathy at this level, right more than left.
3. A postero-central and a right postero-lateral disc herniation at the L3-L4 level with hypertrophic facetal arthropathy on the right and resultant lateral recess stenosis. There is inferior migration of the disc, posterior to the L4 vertebral body with mild indentation upon the L4 nerve roots.
4. Small posterior disc bulges at the L1-L2 and L2-l3 levels with right postero-lateral disc herniation at the L2-L3 level.