ke/bv/rg.
Date : 00.00.00
Name of the Patient : Abc Xyza Plmn / F / 65 yrs.
Referred by : Dr. Abc Xyz Hashim.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the RLE and 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.
There is a large annular disc herniation at the L4-L5 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. Bilateral far lateral disc herniations are also noted at this level with indentation upon the foraminal portion of the L4 nerve roots bilaterally (right more than left). There is a suggestion of inflammation of right L4 nerve root. The L4-L5 facet joints show hypertrophic degenerative changes with ligamentum flavum hypertrophy and resultant canal stenosis. Minimal fluid (effusion) is also seen in the L4-L5 facet joints.
A small posterior disc bulge is noted at the L5-S1 level with left nerual foraminal narrowing.
Type II degenerative changes are noted in the L3 vertebral body adjacent to the L2-L3 intervertebral disc and Type III degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
..2/.
The rest of the lumbar vertebral bodies 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 :
16.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
9.0 mm at L4-L5
8.0 mm at L5-S1.
The right kidney appears slightly smaller as compared to the left.
IMPRESSION :
The MRI features are suggestive of a large annular disc herniation at the L4-L5 level with bilateral far lateral disc herniations indenting the foraminal portion of the L4 nerve roots bilaterally (right more than left) at this level with inflammation of right L4 nerve root and hypertrophic facetal arthropathy and resultant canal stenosis at the L4-L5 level.