Date : 00.00.00
Name of the Patient : Abc Xyzhai lmn / M / 53 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 3 months.
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 vertebral body and the L1 vertebral body is as marked on the film.
There is a right paracentral and right far lateral disc herniation at the L4-L5 level with antero-lateral indentation of the thecal sac and right neural foraminal narrowing. There is indentation upon the extraforaminal portion of the right L4 nerve root. The L4-L5 facet joints on the right side show degenerative changes.
A small postero-central disc herniation is seen at the L3-L4 level. Anterior disc herniation with peridiscal osteophytes is also noted at this level. The L3-L4 and L4-L5 intervertebral discs show loss of water content.
Type II degenerative changes are seen in the antero-inferior aspect of the L2 and L3 vertebral bodies.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebral body and the L1 vertebral body is as marked on the film.
2. A right paracentral and right far lateral disc herniation at the L4-L5 level with indentation upon the extraforaminal portion of the right L4 nerve root and facetal arthropathy on the right side at this level.
3. A small postero-central disc herniation at the L3-L4 level.