ke/hs/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xylmn / M / 58 yrs.
Referred by : Dr. Abc Xyzdy.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE (occasionally) since 1 month.
EXAMINATION :
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.
OBSERVATION :
There is mild retroplacement of the L5 vertebra over the S1 vertebra.
There are posterior and bilateral far lateral disc herniations with small peridiscal osteophytes at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing, left more than right with mild indentation upon the traversing left S1 nerve root. There is minimal indentation upon the extraforaminal portion of the exiting L5 nerve roots bilaterally. There is probable inflammation of the traversing right S1 nerve root.
Posterior and bilateral far lateral disc herniations with small peridiscal osteophytes are noted at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing.
Anterior disc herniations are seen at the L4-L5 and L5-S1 levels. These intervertebral discs show loss of water content.
Facetal hypertrophy is seen at the L4-L5 and L5-S1 levels. Mild ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.
Type II degenerative changes are seen in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
13.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Posterior and bilateral far lateral disc herniations with small peridiscal osteophytes at the L5-S1 level with mild indentation upon the traversing left S1 nerve root and the extraforaminal portion of the exiting L5 nerve roots, bilaterally.
2. Posterior and bilateral far lateral disc herniations with small peridiscal osteophytes at the L4-L5 level.
3. A tight canal at the L4-L5 level.