Date : 00.00.00
Name of the Patient : Abc Xyzsingh Kalmn / M / 37 yrs.
Referred by : Dr. Abc Xyzjor.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE 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.
There is loss of normal lumbar lordosis.
There is sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
There is mild retroplacement of the L3 vertebra over the L4 vertebra.
A large postero-central disc extrusion is seen to indent the thecal sac at the L3-L4 level. A disc portion is seen to lie within the anterior epidural space, more to the left at the L4 vertebral level with impingement of the traversing left L4 nerve root.
A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. A small left postero-lateral disc herniation is seen to cause mild left neural foraminal narrowing at the L3-L4 level.
The L3-L4 and L4-L5 intervertebral discs show loss of water content.
Type II degenerative changes are seen within the vertebral bodies adjacent to the L3-L4 and L4-L5 intervertebral discs.
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 D12 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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A large postero-central disc extrusion at the L3-L4 level with a disc fragment lying within the anterior epidural space, more to the left at the L4 vertebral level impinging the traversing left L4 nerve root.
3. A postero-central disc herniation at the L4-L5 level.