S Date : 00.00.00
Name of the Patient : Abc Xyzka B. Gajlmn / F / 42 yrs.
Referred by : Dr. Abc Xyz Gupta.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with slight paresthesias since 2 months.
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 slight anti-clockwise rotation of the lumbar vertebrae.
A large postero-central disc extrusion is seen to indent the thecal sac at the L5-S1 level. A disc portion is seen to lie within the anterior epidural space and the left lateral recess of the S1 vertebra with resultant impingement of the traversing left S1 nerve root.
A left paracentral disc herniation is seen to indent the thecal sac at the L2-L3 level whereas one on the right side is seen to do the same at the L3-L4 level.
A mild posterior disc bulge is evident at the L4-L5 level.
The right L5-S1 facet joint shows degenerative changes.
The lumbar intervertebral discs except at the L4-L5 level show loss of water content.
A lesion which is hypointense on the T1 Weighted images and turns hyperintense on the T2 Weighted images is seen within the sacral prevertebral region. This most likely represents a cystic lesion (? ovarian, ? fluid fluid level) and requires further evaluation.
The lumbar vertebral bodies reveal normal signal intensity.
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
15.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc extrusion with canal stenosis at the L5-S1 level with a disc portion
seen to lie within the anterior epidural space and the left lateral recess of the S1 vertebra.
2 A left paracentral disc herniation at the L2-L3 level.
3. A right paracentral disc herniation at the L3-L4 level.
4. Facetal arthropathy at the L5-S1 level on the right side.
5. A cystic lesion within the sacral prevertebral region,
which requires further evaluation.