Date : 00.00.00
Name of the Patient : Abc Xyza Chlmn / F / 61 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with numbness since 5-6 days.
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 side and slight forward translation of the L4 over the L5 vertebral body.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. A disc portion is seen to lie in the right lateral recess of the L5 vertebra with resultant impingement of the traversing right L5 nerve root.
Posterior disc herniations are seen to indent the thecal sac and narrow both neural foramina at the L2-L3 and L3-L4 levels. Bilateral far lateral (extraforaminal) disc herniations are noted at these levels.
The L4-L5 and L5-S1 facet joints on the right side and the L3-L4 facet joint on the left side show hypertrophic degenerative changes. The rest of the lumbar facet joints show mild degenerative changes.
- 2 - Scan-00004
There is ligamentum flavum hypertrophy at the L4-L5 and L5 levels. A mild posterior disc bulge is noted at the L5-S1 level.
Posterior peridiscal osteophytes are seen at the L2-L3, L3-L4 and L4-L5 levels. A small posterior disc bulge with small peridiscal osteophytes is noted at the L1-L2 level.
The lumbar intervertebral discs show loss of water content and the L3-L4 intervertebral disc is decreased in height.
The lumbar vertebral bodies show areas of fatty replacement of the normal marrow.
Anterior disc herniations with peridiscal osteophytes are noted at the L2-L3 and L3-L4 levels.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 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 :
16.0 mm at L1-L2
12.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
1. A posterior disc herniation at the L4-L5 level with a disc portion lying in the right lateral recess of the L5 vertebra with resultant impingement of the traversing right L5 nerve root.
- 3 - Scan-00004
2. Posterior disc herniations with bilateral far lateral (extraforaminal) disc herniations at the L2-L3 and L3-L4 levels.
3. Hypertrophic facetal arthropathy at the L4-L5 and L5-S1 levels on the right side and at the L3-L4 level on the left side and mild facetal arthropathy at the rest of the lumbar levels.
4. A tight canal at the L3-L4 and L4-L5 levels.