Date : 00.00.00
Name of the Patient : Abc Xyzand lmn / M / 62 yrs.
Referred by : Dr. Abc Xyzagwati.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE since 2-3 months.
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 retrolisthesis of the L3 vertebra over the L4 vertebra. Also seen is mild retroplacement of the L4 vertebra over the L5 vertebra.
The L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content.
A posterior disc herniation is seen to indent the thecal sac and cause slight neural foraminal narrowing bilaterally at the L4-L5 level.
A left paracentral disc extrusion is seen to indent the ventral aspect of the thecal sac at the L3-L4 level. Also seen is a left postero-lateral (foraminal) disc herniation narrowing the left neural foramen at this level with indentation upon the foraminal portion of the left L3 nerve root.
Far lateral disc bulges are seen bilaterally over the L2-L3 to the L5-S1 levels. A posterior disc bulge is noted at the L5-S1 level.
The L5-S1 facet joints show hypertrophic degenerative changes, left more than right.
Facetal hypertrophy is noted over the L1-L2 to the L4-L5 levels.
Few of the lumbar vertebral bodies show Type II degenerative changes.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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
10.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation with tight lumbar canal at the L4-L5 level.
2. A left paracentral disc extrusion with a left postero-lateral disc herniation and canal stenosis at the L3-L4 level with indentation upon the foraminal portion of the left L3 nerve root.
3. Hypertrophic facetal arthropathy at the L5-S1 level, left more than right.
4. Facetal hypertrophy over the L1-L2 to the L4-L5 levels.