Date : 00.00.00
Name of the Patient : Abc Xyzlya Klmn / F / 44 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) with paresthesias since 4-5 years.
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 loss of water content of the L3-L4 and L4-L5 intervertebral discs.
There is a posteriorly bulging disc with peridiscal osteophytes at the L4-L5 level with bilateral neural foraminal narrowing. A left far lateral disc herniation is noted at this level. There is also hypertrophic facetal arthropathy and ligamentum flavum hypertrophy, more on the left side, with resultant left lateral recess stenosis.
There is slight forward translation of the L3 over the L4 vertebral body.
A left far lateral disc herniation with peridiscal osteophytes is noted at the L3-L4 level with left neural foraminal narrowing. Hypertrophic facetal arthropathy is also noted at this level.
Slight facetal hypertrophy is noted at the L2-L3 level.
Fatty marrow changes are noted in the L4 vertebral body, superiorly.
The rest of 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 D12-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 :
14.0 mm at L1-L2
15.0 mm at L2-L3
12.0 mm at L3-L4
9.0 mm at L4-L5
10.0 mm at L5-S1.
1. A posteriorly bulging disc with a left far lateral disc herniation and peridiscal osteophytes at the L4-L5 level with hypertrophic facetal arthropathy and ligamentum flavum hypertrophy, more on the left side, with resultant left lateral recess stenosis at this level.
2. A left far lateral disc herniation with peridiscal osteophytes at the L3-L4 level with left neural foraminal narrowing and hypertrophic facetal arthropathy at that level.
3. Slight facetal hypertrophy at the L2-L3 level.