Date : 00.00.00
Name of the Patient : Abc Xyz Klmn / M / 49 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the RLE.
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 loss of normal lumbar lordosis. The L3-L4, L4-L5 and L5-S1 intervertebral discs show mild loss of water content.
There is mild forward translation of the L4 over the L5 vertebra.
A large postero-central disc extrusion is seen to compress upon the thecal sac at the L4-L5 level. Also seen is slight inferior migration of this disc portion.
A right paracentral disc herniation is seen to indent the ventral aspect of the thecal sac at the L3-L4 level.
There is a small left postero-lateral (foraminal) disc herniation at the L5-S1 level. A posterior disc bulge is noted at the L2-L3 level. Bilateral far lateral (extraforaminal) disc bulges are seen at the L3-L4 and L4-L5 levels.
The L3-L4 and L4-L5 facet joints show degenerative changes.
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 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
14.0 mm at L2-L3
11.0 mm at L3-L4
8.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc extrusion with canal stenosis at the L4-L5 level.
2. A right paracentral disc herniation at the L3-L4 level.