Date : 00.00.00
Name of the Patient : Abc Xyzamad Al-Buslmn / M / 44 yrs
Referred by : Dr. Abc Xyzmani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with paresthesias since 8 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 L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content.
There is mild retrolisthesis of the L3 over the L4 vertebral body.
A large posterior and left paracentral disc herniation is seen at the L3-L4 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. A large peridiscal osteophyte is seen to arise from the postero-inferior aspect of the L3 vertebral body. The L3-L4 facet joints show degenerative changes with resultant tight canal.
A posterior and right paracentral disc herniation is noted at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints also show degenerative changes.
The facet joints at the L5-S1 level also show hypertrophic degenerative changes.
The lumbar vertebral bodies and the remaining intervertebral discs 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
14.0 mm at L2-L3
10.0 mm at L3-L4
12.0 mm at L4-L5
14.0 mm at L5-S1.
The MRI features are suggestive of :
1. Retroplacement of the L3 over the L4 vertebra.
2. A large posterior and left paracentral disc herniation at the L3-L4 level with a large peridiscal osteophyte arising from the postero-inferior aspect of the L3 vertebral body with facetal arthropathy and resultant tight canal.
3. A posterior and right paracentral disc herniation at the L4-L5 level with facetal arthropathy.