Date : 00.00.00
Name of the Patient : Abc XyzR. Galmn / F / 48 yrs.
Referred by : Dr. Abc Xyzhru / Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 1 month.
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.
The L5 vertebra is as marked on the film. (Please correlate with plain radiographs).
The D12-L1, L3-L4 and L4-L5 intervertebral discs show loss of water content.
There is mild forward listhesis of the L3 vertebra over the L4 vertebra.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L3-L4 level. There is slight superior migration of the disc posterior to the L3 vertebra. There is mild indentation upon the foraminal portion of both the exiting L3 nerve roots. Bilateral far lateral (extraforaminal) disc herniations are seen at the L3-L4 level.
A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level.
The L3-L4 facet joints show hypertrophic degenerative changes.
Fat is noted within the filum terminale over the L2 to the L4 level.
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
19.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.
1. Forward listhesis of the L3 vertebra over the L4 vertebra.
2. Posterior and bilateral far lateral (extraforaminal) disc herniations with hypertrophic facetal arthropathy at the L3-L4 level.
3. A postero-central disc herniation at the L4-L5 level.