Date : 00.00.00
Name of the Patient : Abc Xyzal lmn / M / 58 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 8 days.
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 it is as marked on the film. Please correlate with plain radiographs.
A large left postero-lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. There is impingement of the foraminal and the extraforaminal portion of the exiting left L4 nerve root. The L4-L5 facet joints bilaterally show degenerative changes. There is probable inflammation of the left L4 nerve root.
A small left far lateral (extraforaminal) disc bulge is noted at the L3-L4 level. The L4-L5 disc is seen to bulge posteriorly.
Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.
The L3-L4 and L4-L5 intervertebral discs show loss of water content.
- 2 - Scan-00004
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
13.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. A large left postero-lateral disc herniation at the L4-L5 level impinging the foraminal and the extraforaminal portion of the exiting left L4 nerve root with facetal arthropathy bilaterally at this level.
3. A small left far lateral (extraforaminal) disc bulge at the L3-L4 level.