Date : 00.00.00
Name of the Patient : Abc Xyza Plmn / F / 35 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias.
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 diffuse posterior disc herniation with peridiscal osteophytes at the L4-L5 level with anterior compression of the thecal sac and bilateral neural foraminal narrowing. Slight inferior migration of the disc is noted with indentation upon the L5 nerve roots bilaterally. The L4-L5 facet joints appear slightly hypertrophied with mild ligamentum flavum hypertrophy and resultant canal stenosis.
A small right far lateral disc bulge is seen at the L2-L3 level and a small posterior disc bulge at the L5-S1 level.
The L2-L3 and L4-L5 intervertebral discs show loss of water content.
The facet joints at the L5-S1 level also appear slightly hypertrophied.
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 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
12.0 mm at L2-L3
13.0 mm at L3-L4
6.0 mm at L4-L5
11.0 mm at L5-S1.
1. A diffuse posterior disc herniation with peridiscal osteophytes at the L4-L5 level with slight inferior migration of the disc indenting the L5 nerve roots bilaterally. There is facetal hypertrophy and ligamentum flavum hypertrophy with resultant canal stenosis at this level.
2. A small right far lateral disc bulge at the L2-L3 level.
3. A small posterior disc bulge at the L5-S1 level with facetal hypertrophy at this level.