Date : 00.00.00
Name of the Patient : Abc XyzBalilmn / M / 70 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with numbness in BLE since 1 year.
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 lumbar intervertebral discs except L1-L2 disc show loss of water content.
There is a postero-central disc herniation with peridiscal osteophytes at the L5-S1 level and anterior indentation of the thecal sac. Bilateral far lateral (extraforaminal) disc bulges are also noted at this level, right more than left with indentation upon the extraforaminal portion of the L5 nerve roots. There is ligamentum flavum hypertrophy with mild facetal hypertrophy at this level.
A posterior and left postero-lateral (foraminal) disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. The L4-L5 facet joints bilaterally show degenerative changes. Mild ligamentum flavum hypertrophy is seen at the L5 level.
A left paracentral disc herniation is seen at the L3-L4 level with antero-lateral indentation of the thecal sac and mild left neural foraminal narrowing.
Small posterior peridiscal osteophytes are noted at the L2-L3 level. The L2-L3 intervertebral disc appears reduced in height.
The L2-L3 and L3-L4 facet joints show hypertrophic degenerative changes.
Anterior disc herniations are seen at the L2-L3, L3-L4 and L5-S1 levels.
Type II degenerative changes are seen in L2 and L3 vertebral bodies adjacent to the L2-L3 intervertebral disc anteriorly.
The rest of the lumbar vertebral bodies and the L1-L2 intervertebral disc reveals 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
15.0 mm at L3-L4
14.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc herniation with peridiscal osteophytes at the L5-S1 level with ligamentum flavum hypertrophy and mild facetal hypertrophy at this level.
- 3 - Scan-00001
2. A posterior and left postero-lateral disc herniation at the L4-L5 level with facetal arthropathy bilaterally.
3. A left paracentral disc herniation at the L3-L4 level with small posterior peridiscal osteophytes.
4. Hypertrophic facetal arthropathy at the L2-L3 and L3-L4 levels.
5. Tight lumbar canal at the L4-L5 and L5-S1 levels.