Date : 00.00.00
Name of the Patient : Abc Xyza Islmn / F / 53 yrs.
Referred by : Dr. Abc Xyz Ansari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 2 months.
H/O lifting heavy weights.
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.
3 mm thick T1 Weighted coronal images.
There is loss of water content of the lower lumbar intervertebral discs.
Postero-central disc herniations are seen to indent the thecal sac at the L3-L4 and L4-L5 levels.
A small postero-central disc herniation is seen to indent both the traversing S1 nerve roots at the L5-S1 level.
Bilateral far lateral (extraforaminal) disc herniations are seen at the L4-L5 level. The facet joints at this level show hypertrophic degenerative changes, with canal stenosis
The facet joints bilaterally at the L5-S1 level and on the left side at the L3-L4 level show degenerative changes.
Well-circumscribed lesions which are isointense to CSF are seen along the nerve roots within the spinal canal at the S1 vertebral level and these would represent Tarlovs (perineurial) cysts.
A focal lesion on all the pulse sequences is seen within the L1 vertebral body and this most likely represent a hemangioma with high fat content.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the 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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
1. Postero-central disc herniations at the L3-L4 and L4-L5 levels.
2. Hypertrophic facetal arthropathy at the L4-L5 level with canal stenosis.
- 3 - Scan-00004
3. Facetal arthropathy bilaterally at the L5-S1 level and on the left side at the L3-L4 level.
4. A small postero-central disc herniation indenting both the traversing S1 nerve roots at the L5-S1 level.
5 Tarlovs perineurial cysts at the S1 level.
6. A tight canal at the L3-L4 level.