Date : 00.00.00
Name of the Patient : Abc Xyzati Ralmn / F / 40 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 BLE.
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 show loss of water content.
A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. Also seen are right postero-lateral and right far lateral disc herniations with slight right neural foraminal narrowing at the L4-L5 level.
Left postero-lateral and left far lateral disc herniations are seen to narrow the left neural foramen at the L3-L4 level.
The L3-L4 and L4-L5 facet joints show hypertrophic degenerative changes. The L5-S1 facet joint shows mild degenerative changes.
A mild posterior disc bulge is seen at the L5-S1 level.
The lumbar vertebral bodies reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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
16.0 mm at L2-L3
15.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc herniation at the L4-L5 level.
2. Right postero-lateral and right far lateral disc herniations at the L4-L5 level.
3. Left postero-lateral and left far lateral disc herniations at the L3-L4 level.
4. Hypertrophic facetal arthropathy at the L3-L4 and L4-L5 levels.