Date : 00.00.00
Name of the Patient : Abc XyzS. lmn / F / 45 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 3 months.
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 L4-L5 and L5-S1 intervertebral discs show loss of water content.
The L5 vertebra is as marked on the film.
There is a left postero-lateral disc herniation at the L5-S1 level indenting the exiting left S1 nerve root. Mild left neural foraminal narrowing is noted at this level. Mild ligamentum flavum and facetal hypertrophy is also seen at this level with resultant canal stenosis.
A small posterior disc herniation is seen at the L4-L5 level. The L4-L5 facet joints show degenerative changes.
Type II degenerative changes is noted in the L5 vertebral body adjacent to the L5-S1 intervertebral disc.
The rest of the lumbar vertebral bodies and the remaining 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 L1 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 :
15.0 mm at L1-L2
13.0 mm at L2-L3
12.0 mm at L3-L4
11.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. A left postero-lateral disc herniation at the L5-S1 level indenting the exiting left S1 nerve root with facetal and ligamentum flavum hypertrophy with canal stenosis at this level.
2. A small posterior disc herniation at the L4-L5 level with facetal arthropathy.