Date : 00.00.00
Name of the Patient : Abc Xyzslmn / M / 53 yrs.
Referred by : Dr. Abc Xyzykar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE with paresthesias since 4 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.
The lumbar intervertebral discs show loss of water content.
There is a break of the pars interarticularis of the L5 vertebra bilaterally.
Posterior disc herniations with peridiscal osteophytes are seen to indent the thecal sac and narrow both neural foramina at the L4-L5 and L5-S1 levels.
A postero-central disc herniation with peridiscal osteophytes, more to the left of the midline is seen to indent the thecal sac at the L1-L2 level.
The L4-L5 and L5-S1 facet joints show mild degenerative changes. The left L3-L4 facet joint shows hypertrophic degenerative changes.
A right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L5 nerve root at the L5-S1 level.
An anterior disc herniation is noted at the L5-S1 level. Type I degenerative changes (hypointense on the T1 Weighted images and hyperintense on the T2 Weighted images) are seen within the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc. Hypointense areas on all the pulse sequences suggestive of calcium/vacuum phenomena are seen within the L5-S1 intervertebral disc.
Fat is noted within the filum from the L2-L3 level downwards.
The rest of the lumbar vertebral bodies 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 :
16.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
13.0 mm at L5-S1.
The MRI features are suggestive of :
1. Spondylolysis of the L5 vertebra.
2. Posterior disc herniations with peridiscal osteophytes and mild facetal arthropathy at the L4-L5 and L5-S1 levels.
- 3 - Scan-00007
3. A postero-central disc herniation with peridiscal osteophytes, more to the left of the midline at the L1-L2 level.
4. Hypertrophic facetal arthropathy on the left side at the L3-L4 level.
5. A right far lateral (extraforaminal) disc herniation
at the L5-S1 level.