Date : 00.00.00
Name of the Patient : Abc XyzShilmn / F / 44 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with 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.
The S1 vertebral body is as marked on the film.
There is a right postero-lateral disc herniation with large peridiscal osteophytes at the L5-S1 level. There is resultant right neural foraminal narrowing and mild indentation upon the foraminal portion of the right L5 nerve root. Slight inferior migration of the disc is noted. This disc shows loss of water content.
The L3-L4 and L4-L5 facet joints show degenerative changes.
The dorsal spine was screened with 4 mm thick T2 Weighted sagittal images which shows slight increase in the diameter of the dorsal spinal cord upto the conus cauda level and a hyperintense signal from the D4 level downwards upto the conus cauda.
A small posterior disc bulge with peridiscal osteophyte is noted at the D12-L1 level.
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 :
13.0 mm at L1-L2
14.0 mm at L2-L3
16.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.
1. A right postero-lateral disc herniation with large peridiscal osteophytes at the L5-S1 level with mild indentation upon the foraminal portion of the right L5 nerve root.
2. Facetal arthropathy at the L3-L4 and L4-L5 levels.
3. Slight increase in diameter of the dorsal spinal cord from D4 level upto the conus cauda with altered signal within the cord may be the sequelae of previous arachnoiditis/myelitis.
4. A small posterior disc bulge with peridiscal osteophyte at the D12-L1 level.
If clinically indicated, a dedicated study of the dorsal cord with contrast may be obtained.