Date : 00.00.00
Name of the Patient : Abc Xyzkala Plmn / F / 60 yrs.
Referred by : Dr. Abc Xyzchale.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O weakness of the LLE since 00.00.00.
Now C/O paresthesias in the LUE and on the left side of the face.
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.
There is scoliosis of the lumbar spine with convexity to the right.
There is a posterior and right far lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and the extraforaminal portion of the right L4 nerve root. The L4-L5 facet joints show mild degenerative changes.
A small posterior and left postero-lateral disc herniation is noted at the L3-L4 level with mild left neural foraminal narrowing. The L3-L4 facet joints also show mild degenerative changes.
A small posterior disc herniation is seen at the L5-S1 level.
There is a posterior disc bulge at the L2-L3 level. The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies reveal spotty fatty changes suggesting osteoporosis. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 level and the thecal sac terminates at the L5-S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.
The cervico-dorsal and dorsal spines were screened with the help of 4 mm thick T2 Weighted sagittal images and which does not reveal any diagnostic feature of note.
There is no cord compression.
The MRI features are suggestive of :
1 A posterior and right far lateral disc herniation at the L4-L5 level indenting the thecal sac and the extraforaminal portion of the right L4 nerve root.
2 A small posterior and left postero-lateral disc herniation at the L3-L4 level.