Date : 00.00.00
Name of the Patient : Abc Xyz Ralmn / F / 77 yrs.
Referred by : Dr. Abc Xyzhauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias.
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 a diffuse posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Gross ligamentum flavum hypertrophy is noted at this level with resultant severe canal stenosis.
A small posterior disc herniation with left far lateral disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac and left neural foraminal narrowing. Ligamentum flavum hypertrophy is also seen at this level.
Small posterior disc bulges are noted at the L1-L2, L2-L3 and L5-S1 levels.
Ligamentum flavum hypertrophy is seen at the L5 and L5-S1 levels.
Posterior peridiscal osteophytes are noted in the lumbar region.
Anterior disc herniations are seen in the lumbar region with anterior peridiscal osteophytes. The lumbar intervertebral discs show loss of water content. Hypointense areas are seen within the L3-L4, L4-L5 and L5-S1 intervertebral discs on all the pulse sequences suggestive of calcification/vacuum phenomenon.
Focal fatty changes are noted in the lumbar region.
The facet joints in the lower lumbar region appear hypertrophied. 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 :
11.0 mm at L1-L2
13.0 mm at L2-L3
11.0 mm at L3-L4
6.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A diffuse posterior disc herniation at the L4-L5 level with gross ligamentum flavum hypertrophy.
2. A small posterior disc herniation with left far lateral disc herniation at the L3-L4 level
- 3 - Scan-00006
3. Small posterior disc bulges at the L1-L2, L2-L3 and L5-S1 levels.
4. Ligamentum flavum hypertrophy at the L3-L4, L5 and L5-S1 levels and facetal hypertrophy in the lumbar region.
5. Posterior peridiscal osteophytes in the lumbar region.
6. Canal stenosis at the L3-L4, L4-L5 and L5-S1 levels (maximum at the L4-L5 level).