Date : 00.00.00
Name of the Patient : Abc Xyzlmn / F / 45 yrs.
Referred by : Dr. Abc Xyzra.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with numbness since 2-3 months.
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 slight retroplacement of the L5 over the S1 vertebral body.
The lumbar intervertebral discs show loss of water content.
A pseudoposterior disc herniation is seen at the L5-S1 level with peridiscal osteophytes and anterior indentation of the thecal sac and mild left neural foraminal narrowing. There is inferior migration of the disc with indentation on the S1 nerve roots, bilaterally more on the left side.
A small posterior and left far lateral disc bulge is seen at the L4-L5 level.
The facet joints at the L4-L5 and L5-S1 levels show hypertrophic changes.
A posterior disc herniation is noted at the L3-L4 level and a postero-central disc protrusion at the L2-L3 level with peridiscal osteophytes.
A small left far lateral disc bulge is seen at the L1-L2 level. Schmorls node is noted in the superior aspect of the L4 vertebral body.
Type II degenerative changes are noted in the antero-inferior aspect of the L5 vertebral body.
The rest of the lumbar vertebral bodies reveal normal signal intensity. 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at L1-L2
11.0 mm at L2-L3
11.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
1. Slight retroplacement of the L5 over the S1 vertebral body.
2. A pseudoposterior disc herniation at the L5-S1 level with inferior migration of the disc indenting the S1 nerve roots (more on the left side).
3. A small posterior and left far lateral disc bulge at the L4-L5 level.
4. A posterior disc herniation at the L3-L4 level.
5. A postero-central disc protrusion with peridiscal osteophytes at the L2-L3 level.