Date : 00.00.00
Name of the Patient : Abc Xylmn / M / 50 yrs.
Referred by : Dr. Abc Xyzna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache 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 lumbar intervertebral discs except for the L5-S1 intervertebral disc show loss of water content.
There is a posterior disc herniation, slightly to the right of the midline at the L4-L5 level with anterior indentation of thecal sac and bilateral neural foraminal narrowing. Inferior migration of the disc posterior to L5 is noted with indentation upon the L5 nerve roots, bilaterally, more on the right side. The L4-L5 facet joints show slight degenerative changes. Ligamentum flavum hypertrophy is noted at the L5 level, with tight lumbar canal.
Small posterior disc bulges are seen at the L3-L4 and L5-S1 levels. A right far lateral disc bulge is seen at the L1-L2 level.
Anterior disc herniation is seen at the L1-L2 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 :
16.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of a posterior disc herniation, slightly to the right of the midline at the L4-L5 level with inferior migration of the disc posterior to L5 with indentation on the traversing L5 nerve roots bilaterally, (right more than left) with facetal arthropathy, ligamentum flavum hypertrophy at the L5 level and tight lumbar canal.