Date : 00.00.00
Name of the Patient : Abc Xyzli lmn / M / 40 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Alleged H/O fall of heavy weight on back on 00.00.00.
C/O weakness of BLE since 00.00.00.
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 curvature.
The lumbar intervertebral discs show loss of water content.
There is a large left postero-lateral and far lateral disc herniation at the L3-L4 level with antero-lateral indentation of the thecal sac and left neural foraminal narrowing and canal stenosis. Part of the disc is seen to migrate inferiorly posterior to the L4 vertebra. There is resultant indentation upon the extraforaminal portion of the left L3 nerve root. Right far lateral disc herniation is also noted at this level with mild indentation upon the extraforaminal portion of the right L3 nerve root. The facet joints at this level show hypertrophic changes.
There is a large posterior and right postero-lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show degenerative changes.
- 2 - Scan-00006
Small posterior disc bulges are noted at the L2-L3 and L5-S1 levels.
The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
Sclerotic changes are seen in the S1 vertebral body.
The remaining of the lumbar vertebral bodies 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 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
11.0 mm at L2-L3
8.0 mm at L3-L4
7.0 mm at L4-L5
10.0 mm at L5-S1.
The cervico-dorsal and the dorso-lumbar spine was screened with 4 mm thick T2 Weighted sagittal images which show small posterior disc bulges at the C5-C6 and C6-C7 levels.
The MRI features are suggestive of :
1. A large left postero-lateral and far lateral disc herniation at the L3-L4 level indenting the thecal sac and extraforaminal portions of the L3 nerve roots with a part of the disc seen posterior to the L4 vertebra with facetal hypertrophy and canal stenosis.
2. A large posterior and right postero-lateral disc herniation at the L4-L5 level with facetal arthropathy.
3. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.