s Date : 00.00.00
Name of the Patient : Abc Xyzanglmn / M / 71 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (left more than right) with numbness in the LLE.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
Posterior disc herniations are seen to indent the thecal sac and narrow both neural foramina at the L3-L4 and L4-L5 levels. A disc portion is seen to lie within the left lateral recess of the L4 vertebra with resultant impingement of the traversing left L4 nerve root.
A postero-central disc herniation is seen to indent the thecal sac at the L5-S1 level.
Bilateral far lateral (extraforaminal) disc herniations are noted at the L3-L4 level. Bilateral far lateral (extraforaminal) disc bulges are noted at the L2-L3 and L4-L5 levels.
The L4-L5 and L5-S1 facet joints show severe hypertrophic degenerative changes. Mild hypertrophic degenerative changes of the facet joints are noted at the L1-L2, L2-L3 and L3-L4 levels. There is ligamentum flavum hypertrophy at the L5 level.
- 2 - Scan-00003
The lumbar intervertebral discs show loss of water content. The lumbar vertebral bodies show spotty areas of fatty replacement of normal marrow suggestive of osteoporotic changes.
A cortical cyst is noted at the superior pole of the right kidney.
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 :
11.0 mm at L1-L2
11.0 mm at L2-L3
9.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. Posterior disc herniations at the L3-L4 and L4-L5 levels with canal stenosis at these levels. A disc portion is seen to lie within the left lateral recess of the L4 vertebra with resultant impingement of the traversing left L4 nerve root.
- 3 - Scan-00003
2. A postero-central disc herniation at the L5-S1 level.
3. Bilateral far lateral (extraforaminal) disc herniations at the L3-L4 level.
4. Severe hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels.
5. Mild hypertrophic facetal arthropathy at the L1-L2, L2-L3 and L3-L4 levels.