Date : 00.00.00
Name of the Patient : Abc XyzDelmn / F / 59 yrs.
Referred by : Dr. Abc Xyzrikh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with foot drop on the left side since 00.00.00.
H/O interstitial lung disease detected 3 months back. On Steroids since 3 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 is sacralization of the L5 vertebral body and the L1 vertebral body is as marked on the film.
There is a left paracentral disc extrusion at the L3-L4 level with anterior indentation of the thecal sac. Inferior migration of the disc is seen in the left lateral recess of the L4 vertebra and impingement of the left L4 nerve root (scans 103.4, 106.8, 105.5, 105.4).
Posterior and bilateral far lateral disc herniations are seen at the L4-L5 level with anterior indentation of the thecal sac and left neural foraminal narrowing. There is mild indentation upon the extraforaminal portion of both the L4 nerve roots. The L4-L5 facet joints bilaterally show hypertrophic degenerative changes.
The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
- 2 - Scan-00005
The conus medullaris terminates at the 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 :
21.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebral body.
2. A left paracentral disc extrusion at the L3-L4 level with inferior migration of the disc seen in the left lateral recess of the L4 vertebra with impingement of the left L4 nerve root.
3. Posterior and bilateral far lateral disc herniations at the L4-L5 level with mild indentation upon the extraforaminal portion of L4 nerve roots and facetal arthropathy bilaterally.