A Date : 00.00.00
Name of the Patient : Abc Xyzhan Tholmn / M / 45 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O neckpain and backache with pain radiating to BUE and RLE with paresthesias in BUE since 1-2 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 loss of normal lumbar lordosis. The L4-L5 intervertebral disc shows mild loss of water content.
A large posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. The facet joints at this level show hypertrophic degenerative changes.
Ligamentum flavum hypertrophy is seen at the L4-L5 and L5 levels.
A posterior disc bulge is noted at the L5-S1 level.
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 D12 level and the thecal sac terminates at the S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
7.0 mm at L4-L5
8.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large posterior disc herniation with peridiscal osteophytes, hypertrophic facetal arthropathy and canal stenosis at the L4-L5 level.
2. Ligamentum flavum hypertrophy at the L4-L5 and L5 levels.