hs/ke/nl/rg.
Date : 00.00.00
Name of the Patient : Abc XyzB. Mandalmn / F / 56 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the LLE with paresthesias.
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 :
The lumbar intervertebral discs show loss of water content.
A large posterior disc extrusion, more to the left of the midline is seen to indent the thecal sac and narrow both neural foramina at the L5-S1 level. A disc portion is seen to lie within the anterior epidural space and left lateral recess at the S1 level with impingement of the traversing left S1 nerve root and mild indentation upon the traversing right S1 nerve root. Facetal hypertrophy is noted at the L5-S1 levels.
Mild facetal and ligamentum flavum hypertrophy is noted at the L3-L4 and L4-L5 levels.
Posterior disc bulges are seen at the L3-L4 and L4-L5 levels.
Fat is seen within the filum terminale in the lumbar region.
Incidental note is made of an extrarenal pelvis bilaterally.
The lumbar vertebral bodies reveal normal signal intensity. The remaining 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
13.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A large posterior disc extrusion, more to the left of the midline and facetal hypertrophy with canal stenosis at the L5-S1 level. A disc portion is lying within the anterior epidural space and left lateral recess at the S1 level with impingement of the traversing left S1 nerve root and mild indentation upon the traversing right S1 nerve root.
2. Posterior disc bulges and mild facetal and ligamentum flavum hypertrophy at the L3-L4 and L4-L5 levels.
3. A tight canal at the L4-L5 level.