Date : 00.00.00
Name of the Patient : Abc Xyz Shlmn / F / 35 yrs.
Referred by : Dr. Abc Xyzsari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (left more than right) with paresthesias since 2-3 years.
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 mild retroplacement of the L4 vertebra over the L5 vertebra.
The L4-L5 and L5-S1 intervertebral discs show loss of water content.
A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L5-S1 level. Bilateral far lateral (extraforaminal) disc bulges are seen at this level.
A small postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. The facet joints at this level show degenerative changes.
The L5-S1 facet joints show hypertrophic degenerative changes.
Type I (hypointense on the T1 Weighted and hyperintense on the T2 Weighted images) and Type II (isointense to fat) degenerative changes are seen within the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.
The uterus appears to be slightly bulky.
The rest of 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
17.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
14.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation with peridiscal osteophytes at the L5-S1 level.
2. Hypertrophic facetal arthropathy at the L5-S1 level.
3. A small postero-central disc herniation with facetal arthropathy at the L4-L5 level.