Date : 00.00.00
Name of the Patient : Abc Xyzi Blmn / F / 60 yrs.
Referred by : Dr. Abc Xyzrkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 1 year.
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 lumbar intervertebral discs show loss of water content.
There is a large posterior disc herniation at the L3-L4 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. The L3-L4 facet joints show hypertrophic degenerative changes with resultant central and lateral canal stenosis.
A posterior and right far lateral disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac, bilateral neural foraminal narrowing and impingement of the foraminal and the extraforaminal portion of the right L4 nerve root. The L4-L5 facet joints show hypertrophic degenerative changes with ligamentum flavum hypertrophy at the L4-L5 and L5 levels and canal stenosis.
A small postero-central disc protrusion is noted at the L1-L2 and posterior disc bulges at the L2-L3 and L5-S1 levels with narrowing of the neural foramen bilaterally at the L5-S1 level.
The D12-L1, L1-L2, L2-L3 and the L5-S1 facet joints show degenerative changes with minimal effusion on the right side at the L2-L3 level.
A hemangioma with fatty content is noted within the D12 and L4 vertebral bodies.
Focal fatty changes are noted in the L2, L3 and L4 vertebral bodies.
The rest of the lumbar vertebral bodies 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 S1-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
10.0 mm at L1-L2
13.0 mm at L2-L3
8.0 mm at L3-L4
8.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large posterior disc herniation at the L3-L4 level with hypertrophic facetal arthropathy and resultant central and lateral canal stenosis at this level.
2. A posterior and right far lateral disc herniation at the L4-L5 level with impingement of the foraminal and the extraforaminal portion of the right L4 nerve root.
Also seen is hypertrophic facetal arthropathy at the L4-L5 level with ligamentum flavum hypertrophy and canal stenosis at the L4-L5 and L5 levels.
- 2 - Scan-00001
3. A small postero-central disc protrusion at the L1-L2 level.
4. Facetal arthropathy at the D12-L1, L1-L2, L2-L3 and the L5-S1 levels with minimal effusion on the right side at the L2-L3 level.