Date : 00.00.00
Name of the Patient : Abc Xyzdevi Karlmn / F / 45 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 6-7 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 appears to be sacralization of the L5 vertebra and the D12 vertebra is as marked on the film.
A large posterior disc herniation is seen to compress upon the thecal sac and narrow both neural foramina at the L4-L5 level.
A posterior disc bulge is seen at the L3-L4 level. Also seen is a left postero-lateral (foraminal) disc protrusion at this level.
Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4 and L4-L5 levels.
The L4-L5 facet joints show hypertrophic degenerative changes. Facetal hypertrophy is seen at the L3-L4 level.
The L3-L4 and L4-L5 intervertebral discs show loss of water content.
Limbus L4 and L5 vertebrae are noted.
Type II degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
The rest of 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 D12-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 :
14.0 mm at L1-L2
13.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
6.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large posterior disc herniation with hypertrophic facetal arthropathy and a tight canal at the L4-L5 level.
2. A posterior disc bulge, a left postero-lateral (foraminal) disc protrusion and facetal hypertrophy at the L3-L4 level.
3. Sacralization of the L5 vertebra.