Date : 00.00.00
Name of the Patient : Abc Xyzjivi Shlmn / M / 44 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE and 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 a posterior and a right postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, right more than left. A large free fragment is seen in the right lateral recess of the L5 vertebral body with impingement of the right L5 nerve root.
A posterior disc herniation with large peridiscal osteophytes is noted at the L5-S1 level. A right far lateral disc bulge is also noted at this level.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
Type II degenerative changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 disc and in the antero-superior portion of the L2, L3 and L4 vertebral bodies. There is a suggestion of hemangioma with fatty content in the D12 vertebral body.
A probable conjoint right sided L5/S1 nerve root is noted.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
1. A posterior and a right postero-lateral disc herniation with peridiscal osteophyte at the L4-L5 level with a large free fragment is seen in the right lateral recess of the L5 vertebral body with impingement of the right L5 nerve root.
2. A posterior disc herniation with large peridiscal osteophytes at the L5-S1 level and a right far lateral disc bulge at this level.
3. A probable conjoint right sided L5/S1 nerve root.