Date : 00.00.00
Name of the Patient : Abc Xyzth Suryawalmn / M / 46 yrs.
Referred by : Dr. Abc Xyzh / Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 1 1/2 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.
A posterior disc herniation with peridiscal osteophytes is seen at the L4-L5 level with resultant indentation upon the thecal sac and bilateral neural foraminal narrowing. A left far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting L4 nerve root at the L4-L5 level. This intervertebral disc shows loss of water content.
The L4-L5 and L5-S1 facet joints show degenerative changes. Mild ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.
Mild facetal hypertrophy is seen at the L3-L4 level.
There are far lateral disc bulges bilaterally at the L2-L3 and L3-L4 levels and on the right side at the L4-L5 level.
A mild posterior disc bulge is seen at the L5-S1 level.
A focal hyperintensity on all the pulse sequences is seen within the L2 vertebral body and this may represent a hemangioma with high fat content.
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 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 :
18.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation with peridiscal osteophytes with a tight canal at the L4-L5 level.
2. A left far lateral (extraforaminal) disc herniation at the L4-L5 level.
3. Facetal arthropathy at the L4-L5 and L5-S1 levels.
4. Mild ligamentum flavum hypertrophy at the L4-L5 and L5 levels.