Date : 00.00.00
Name of the Patient : Abc Xyzz Fallahzlmn / F / 64 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the RLE with 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.
There is scoliosis of the lumbar spine with convexity to the right side. Clockwise rotational anomaly of the upper lumbar vertebrae is noted.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. Bilateral far lateral (extraforaminal) disc herniations are seen to indent the extraforaminal portion of both exiting L4 nerve roots at this level.
A small posterior disc herniation is seen at the L5-S1 level with mild indentation upon the thecal sac and slight neural foraminal narrowing bilaterally at this level.
Large right postero-lateral and far lateral disc herniations are seen to narrow the right neural foramina at the L1-L2 and L2-L3 levels.
A small left postero-lateral disc herniation is noted at the L1-L2 level. A small left far lateral (extraforaminal) disc herniation is seen at the L3-L4 level.
Bilateral far lateral (extraforaminal) disc herniations are seen at the L5-S1 level with indentation upon the extraforaminal portion of the exiting right L5 nerve root.
The facet joints bilaterally at the L2-L3, L3-L4 and L4-L5 levels and on the right side at the L5-S1 level show hypertrophic degenerative changes. The L1-L2 facet joints show degenerative changes.
The lumbar intervertebral discs show loss of water content. Few lumbar vertebrae show Type II degenerative changes.
The rest of 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 S2 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
18.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation and bilateral far lateral (extraforaminal) disc herniations at the L4-L5 level.
2. A small posterior disc herniation and bilateral far lateral (extraforaminal) disc herniations at the L5-S1 level.
- 3 - Scan-00008
3. Hypertrophic facetal arthropathy at the L2-L3, L3-L4 and L4-L5 levels and on the right side at the L5-S1 level and facetal arthropathy at the L1-L2 level.
4. Large right postero-lateral and far lateral disc herniations at the L1-L2 and L2-L3 levels.