Date : 00.00.00
Name of the Patient : Abc Xyz Nalmn / F / 45 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE and paresthesias since 8 days.
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 a postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with anterior indentation of the thecal sac. A disc fragment is noted in the right lateral recess of the L5 vertebral body with impingement of the traversing right L5 nerve root. This disc shows loss of water content.
A small right postero-lateral (foraminal) disc herniation is noted at the L3-L4 level with right neural foraminal narrowing.
The L4-L5 facet joint on the left side shows hypertrophic degenerative change with left neural foraminal narrowing.
The L2-L3, L3-L4 and L5-S1 facet joints also show mild degenerative changes.
The lumbar vertebral bodies show preponderance of hematopoietic marrow. 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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
13.0 mm at L5-S1.
1. A postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with a disc fragment in the right lateral recess of the L5 vertebral body impinging the traversing right L5 nerve root.
2. Hypertrophic facetal arthropathy at the L4-L5 level on the left side.
3. Mild facetal arthropathy at the L2-L3, L3-L4 and L5-S1 levels.
4. A right postero-lateral (foraminal) disc herniation at the L3-L4 level.