Date : 00.00.00
Name of the Patient : Abc Xyzon Bharlmn / M / 67 yrs.
Referred by : Dr. Abc Xyznshah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with numbness.
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 sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
There is loss of water content of the lumbar intervertebral discs. There is evidence of calcium/vacuum phenomena in the L1-L2, L4-L5 and L2-L3 intervertebral discs.
There is a posterior disc bulge with a central protrusion at the L4-L5 level, indenting the dural theca anteriorly.
A left far lateral (extraforaminal) disc herniation is noted at the L2-L3 level, with resultant indentation of the L2 nerve root.
A right paracentral and a left postero-lateral (foraminal) protruded disc is also noted at the L1-L2 level.
The lumbar vertebral bodies show spotty fatty changes of the normal marrow. The facet joints in the lumbar region show hypertrophic degenerative changes, maximum at the L4-L5 level with resultant canal stenosis at that level. 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 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.2 mm at L1-L2
17.6 mm at L2-L3
18.4 mm at L3-L4
12.9 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. A posterior disc bulge with a central protrusion at the L4-L5 level.
3. A left far lateral (extraforaminal) disc herniation at the L2-L3 level, with resultant indentation on the left L2 nerve root.
4. A right paracentral and a left postero-lateral (foraminal) protruded disc at the L1-L2 level.
5. Hypertrophic degenerative changes of the lumbar facet joints, maximum at the L4-L5 level with resultant canal stenosis at the L4-L5 level.
As compared to the previous MRI (study no:00001) dated 00.00.00, there is no significant change noted.