Date : 00.00.00
Name of the Patient : Abc Xyzassilmn / M / 47 yrs.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 2-4 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 loss of normal lumbar lordosis and loss of water content of the L4-L5 intervertebral disc.
There is a fairly large, postero-central and left postero-lateral disc herniation at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. A sequestered disc fragment is noted in the right lateral recess of L5, impinging the traversing right L5 nerve root (the sequestered fragment is seen to extend upto the L5-S1 disc). There is also facetal hypertrophy at this level with resultant canal stenosis.
A small postero-central protruded disc is noted at the L3-L4 level.
The facet joints at the L3-L4 and L5-S1 levels appear slightly hypertrophied.
Schmorls nodes are noted in the dorso-lumbar region.
- 2 - Scan-00004
Type II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.
The rest of 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-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 :
12.0 mm at L1-L2
12.0 mm at L2-L3
10.0 mm at L3-L4
8.0 mm at L4-L5
12.0 mm at L5-S1.
The left ureter appears dilated as compared to the right side.
1. A fairly large, postero-central and left postero-lateral disc herniation at the L4-L5 level with bilateral neural foraminal narrowing with a sequestered disc fragment in the right lateral recess of L5, impinging the traversing right L5 nerve root There is also facetal hypertrophy at this level with resultant canal stenosis.
2. Facetal hypertrophy at the L3-L4 and L5-S1 levels.