Date : 00.00.00
Name of the Patient : Abc XyzPlmn / M / 62 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE.
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 mild retroplacement of the L3 over the L4 and L4 over the L5 and slight forward translation of the L5 over the S1 vertebrae.
There is a small postero-central disc herniation with peridiscal osteophytes indenting the thecal sac at the L5-S1 level. Small right postero-lateral and right far lateral disc herniations are also noted at this level with mild indentation upon the foraminal portion of the exiting right L5 nerve root (se/im 102/7). There is probable inflammation
of this nerve root.
A small postero-central disc herniation with peridiscal osteophytes is seen at the L4-L5 level. Also seen is a left postero-lateral (foraminal) disc herniation with peridiscal osteophytes narrowing the left neural foramen at the L4-L5 level. A small left far lateral (extraforaminal) disc herniation is seen at this level.
There is a posterior disc bulge at the L3-L4 level with a protrusion, centrally.
The lumbar intervertebral discs show loss of water content.
The lumbar facet joints show mild degenerative changes.
The lumbar vertebral bodies show normal signal intensity. 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
16.0 mm at L3-L4
14.0 mm at L4-L5
13.0 mm at L5-S1.
The MRI features are suggestive of :
1. Small postero-central disc herniations with peridiscal osteophytes at the L4-L5 and L5-S1 levels.
2. Small right postero-lateral and right far lateral disc herniations indenting the foraminal portion of the exiting right L5 nerve root at the L5-S1 level.
3. Left postero-lateral (foraminal) and small left far lateral disc herniations at the L4-L5 level.
4. Mild facetal arthropathy in the lumbar region.
As compared to the previous MRI dated 00.00.00, there is no significant change.