Date : 00.00.00
Name of the Patient : Abc Xyzuddin Siddlmn / M / 40 yrs.
Referred by : Dr. Abc Xyzpadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 2 years.
H/O ? spinal surgery 2 years back (details not available).
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 L4-L5 and L5-S1 intervertebral discs show loss of water content and the L4-L5 disc appears reduced in height.
There is suggestion of hemilaminectomy on the left side at the L5 level.
A posterior and a left postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, more marked on the left side. There is impingement of the foraminal left L4 nerve root. The L4-L5 facet joints show mild degenerative changes. There is retroplacement of the thecal sac at this level.
A small posterior disc herniation is seen at the L5-S1 level.
Type I degenerative change is noted in the L5 vertebral body adjacent to the L4-L5 intervertebral disc.
Hemangioma with fatty content is noted in the S1 vertebral body.
Anterior disc herniation with peridiscal osteophytes is seen at the L4-L5 level.
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 D12-L1 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
Both the hip joints were screened with 5 mm thick T1 Weighted coronal images which does not reveal any diagnostic feature of note.
The MRI features are suggestive of :
1. Post-operative status.
2. A posterior and a left postero-lateral disc herniation at the L4-L5 level with impingement of the left L4 nerve root and mild facetal arthropathy at this level.