Date : 00.00.00
Name of the Patient : Abc XyzRashid lmn / M / 48 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with slight numbness since 0000.
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 L4-L5 and L5-S1 intervertebral discs show loss of water content.
There is a posterior disc extrusion indenting the thecal sac at the L4-L5 level with slight inferior migration of the disc fragment. There is mild neural foraminal narrowing bilaterally at the L4-L5 level. Bilateral far lateral (extraforaminal) disc bulges are seen at this level.
A postero-central disc herniation is seen to indent the traversing S1 nerve roots, (right more than left) and the thecal sac at the L5-S1 level.
The L1-L2, L2-L3, L3-L4 and L4-L5 facet joints show degenerative changes.
Ligamentum flavum hypertrophy is seen at the L4-L5 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 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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc extrusion with ligamentum flavum and facetal hypertrophy with a tight canal at the L4-L5 level.
2. A postero-central disc herniation at the L5-S1 level.
3. Facetal arthropathy also at the L1-L2, L2-L3 and L3-L4 levels.