Date : 00.00.00
Name of the Patient : Abc Xyz Gadlmn / F / 48 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (left more than right) with paresthesias since 15 days.
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.
There appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
Posterior disc herniations are seen to indent the thecal sac and narrow both neural foramina at the L3-L4 and L4-L5 levels. There is impingement of the foraminal portion of the exiting L4 nerve roots bilaterally at the L4-L5 level.
A postero-central disc herniation is seen to indent the thecal sac at the L5-S1 level.
Far lateral (extraforaminal) disc herniations are noted bilaterally at the L4-L5 level and on the right side at the L2-L3 and L3-L4 levels. A left far lateral (extraforaminal) disc bulge is noted at the L3-L4 level.
The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes. The L2-L3 and L5-S1 facet joints show mild degenerative changes.
The lumbar intervertebral discs, more so at the L3-L4 and L4-L5 levels show loss of water content.
A circumscribed area of hyperintensity on all the pulse sequences is noted in the L3 vertebral body and this may represent a hemangioma with high fat content. Type II degenerative changes are noted within the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral 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 S1-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
13.0 mm at L1-L2
12.0 mm at L2-L3
11.0 mm at L3-L4
8.0 mm at L4-L5
8.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. Posterior disc herniations and hypertrophic facetal arthropathy with canal stenosis at the L3-L4 and L4-L5 levels.
3. A postero-central disc herniation at the L5-S1 level.
4. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels and mild hypertrophic facetal arthropathy at the L2-L3 and L5-S1 levels.
5. Far lateral (extraforaminal) disc herniations bilaterally at the L4-L5 level and on the right side at the L2-L3 and L3-L4 levels.