Date : 00.00.00
Name of the Patient : Abc XyzQurlmn / F / 36 yrs.
Referred by : Dr. Abc Xyzspati.
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 small posterior disc herniation, more to the right of the midline which is seen to indent the right S1 nerve root at the L5-S1 level. Small posterior peridiscal osteophytes are also noted at this level.
A posterior disc bulge with a left far lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and the extraforaminal portion of the traversing left L4 nerve root.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
The lower lumbar facet joints show degenerative changes.
Type II degenerative changes are noted in the L3 and L4 vertebral bodies, anteriorly adjacent to the L3-L4 intervertebral disc.
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 L1-L2 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 :
18.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A small posterior disc herniation, with peridiscal osteophytes, more to the right of the midline indenting the right S1 nerve root.
2. A posterior disc bulge with a left far lateral disc herniation at the L4-L5 level indenting the extraforaminal portion of the traversing left L4 nerve root.