Date : 00.00.00
Name of the Patient : Abc XyzSlmn / M / 70 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE and paresthesias.
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 slight retrolisthesis of the L1 over the L2 and L2 over L3 vertebral bodies.
A posterior and a right postero-lateral disc herniation is seen at the L5-S1 level with mild right neural foraminal narrowing. There is slight indentation of the foraminal and the extraforaminal portion of the right L5 nerve root and posterior displacement of the right S1 nerve root. The facet joint on the right side shows degenerative changes.
A postero-central disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac.
A small, posterior disc herniation is noted at the L3-L4 level. A small disc portion is seen to migrate inferiorly in the left lateral recess of the L4 vertebral body with impingement of the traversing left L4 nerve root (scans 104.11, 102.4, 106.7).
Diffuse posterior disc herniations with bilateral far lateral disc bulges are seen at the L1-L2 and L2-L3 levels with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.
Anterior and posterior peridiscal osteophytes are seen at the L1-L2, L2-L3 and L3-L4 levels.
Schmorls nodes are noted in the inferior aspect of the D12, L1 and L2 vertebral bodies in the superior aspect of the L1 vertebral body.
The L3-L4 and L4-L5 facet joints also show degenerative changes.
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 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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.
1. Slight retrolisthesis of the L1 over the L2 and L2 over the L3 vertebral bodies.
2. A small, posterior disc herniation at the L3-L4 level with a small disc portion migrating inferiorly to the left lateral recess of the L4 vertebral body impinging the traversing left L4 nerve root.
- 3 - Scan-00004
3. A posterior and a right postero-lateral disc herniation at the L5-S1 level with slight indentation of the foraminal and the extraforaminal portion of the right L5 nerve root and right S1 nerve root.
4. A postero-central disc herniation at the L4-L5 level.
5. Diffuse posterior disc herniations with bilateral far lateral disc bulges at the L1-L2 and L2-L3 levels
6. Facetal arthropathy at the L3-L4 and L4-L5 levels bilaterally and on the right side at the L5-S1 level.