Date : 00.00.00
Name of the Patient : Abc Xyzi Slmn / F / 60 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 2 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 L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content. Hypointense areas are noted within the L5-S1 intervertebral disc on all the pulse sequences suggestive of calcification/vacuum phenomena.
There is forward subluxation of the L5 over the S1 vertebral body.
There is a posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Slight inferior migration of the disc is seen posterior to the L5 vertebra with impingement of the right L5 nerve root.
A diffuse posterior and bilateral far lateral disc herniation is seen at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. There is mild indentation upon the extraforaminal portion of the right L5 nerve root.
A small posterior disc bulge is noted at the L3-L4 level. The lumbar facet joints show degenerative changes.
There is anterior wedging of the D12 vertebra without any change in signal intensity.
Posterior peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels.
The vertebral bodies show spotty fatty changes suggesting osteoporosis. 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-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 :
13.0 mm at L1-L2
13.0 mm at L2-L3
12.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
Small posterior disc bulge is seen at the D11-D12 level with flavum hypertrophy and tight canal.
- 3 - Scan-00002
The MRI features are suggestive of :
1. Forward subluxation of the L5 over the S1 vertebra.
2. A posterior disc herniation at the L4-L5 level with
inferior migration of the disc with impingement of the right L5 nerve root.
3. A diffuse posterior and bilateral far lateral disc herniations at the L5-S1 level.
4. Lumbar facetal arthropathy.