Date : 00.00.00
Name of the Patient : Abc Xyz Marlmn / M / 42 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 15 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 large postero-central and right postero-lateral disc herniation at the L5-S1 level with anterior indentation of the thecal sac and the traversing S1 nerve roots bilaterally. A right far lateral (extraforaminal) disc herniation is seen to indent the extraforaminal portion of the exiting right L5 nerve root at this level. This disc shows loss of water content. Posterior peridiscal osteophytes are noted at the L5-S1 level. Right neural foraminal narrowing is seen at this level.
The L5-S1 facet joints show degenerative changes. A left far lateral disc bulge is noted at the L5-S1 level.
Posterior disc bulges are noted at the D11-D12 and L4-L5 levels.
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-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
16.0 mm at L4-L5
8.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central and right postero-lateral disc herniation at the L5-S1 level indenting the traversing S1 nerve roots bilaterally.
2. A right far lateral (extraforaminal) disc herniation indenting the extraforaminal portion of the exiting right L5 nerve root at the L5-S1 level.
3. Facetal arthropathy at the L5-S1 level.