Date : 00.00.00
Name of the Patient : Abc Xyz R. Salmn / M / 60 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with numbness 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 appears to be as marked on the film. Please correlate with plain radiographs.
There is loss of normal lumbar lordosis and loss of water content of the L2-L3, L4-L5 and L5-S1 intervertebral discs.
There is a posteriorly herniated disc with a peridiscal osteophyte at the L5-S1 level with bilateral neural foraminal narrowing. A disc fragment is noted in the right lateral recess of S1, indenting the traversing right S1 nerve root. Facetal hypertrophy is also noted at this level with canal stenosis.
Posterior and bilateral far lateral disc herniations are noted at the L4-L5 level with bilateral neural foraminal narrowing. Facetal hypertrophy is also noted at this level with canal stenosis.
Mild facetal hypertrophy is also noted in the rest of the lumbar region. Mild ligamentum flavum hypertrophy is seen at the L5-S1 level.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
14.0 mm at L1-L2
14.0 mm at L2-L3
14.0 mm at L3-L4
13.0 mm at L4-L5
8.0 mm at L5-S1.
1. A posteriorly herniated disc with a peridiscal osteophyte at the L5-S1 level with a disc fragment in the right lateral recess of S1, indenting the traversing right S1 nerve root.
2. Posterior and bilateral far lateral disc herniations at the L4-L5 level.
3. Facetal hypertrophy in the lumbar region as described.
4. Canal stenosis at the L5-S1 level and a tight canal at the L4-L5 level.