Date : 00.00.00
Name of the Patient : Abc XyzSlmn / M / 41 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 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 retroplacement of the L4 vertebra over the L5 vertebra. The lumbar intervertebral discs show loss of water content.
A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. Right postero-lateral and right far lateral disc herniations are seen to narrow the right neural foramina at the L4-L5 level. Slight inferior migration of the disc posterior to L5 is noted.
A small postero-central disc herniation is noted at the L5-S1 level and a small right paracentral disc herniation is seen to indent the thecal sac at the L1-L2 level.
A small postero-central disc protrusion is noted at the L2-L3 level.
There is a posterior disc bulge at the L3-L4 level.
There are far lateral (extraforaminal) disc bulges bilaterally at the L1-L2, L2-L3 and L3-L4 levels and on the left side at the L4-L5 level.
There is mild facetal hypertrophy in the lumbar region (more so in the lower lumbar region).
The lumbar vertebral bodies reveal normal signal intensity. 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
15.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5
14.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc herniation at the L4-L5 level with a right postero-lateral and right far lateral disc herniations at this level.
2. A small postero-central disc herniation at the L5-S1 level.
3. A small right paracentral disc herniation at the L1-L2 level.
4. A small postero-central disc protrusion at the L2-L3 level.