Date : 00.00.00
Name of the Patient : Abc Xlmn / F / 52 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 with numbness since 00.00.00.
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.
5 mm thick T1 Weighted and T2 Weighted coronal images.
There is mild retroplacement of the L3 over the L4 and the L4 over the L5 vertebrae. The L3-L4 and L4-L5 intervertebral discs show loss of water content.
A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. The left L4-L5 facet joint shows hypertrophic degenerative changes. Also seen is ligamentum flavum hypertrophy at this level.
There is facetal hypertrophy on the right side at the L4-L5 level and bilaterally at the L3-L4 and L5-S1 levels.
Small posterior peridiscal osteophytes are noted at the L3-L4 level.
The nerve root sleeves in the lower lumbar and sacral region appear to be baggy (?? perineurial cysts).
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 D12-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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
9.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation with peridiscal osteophytes, hypertrophic facetal arthropathy on the left side and ligamentum flavum hypertrophy with canal stenosis at the L4-L5 level.
2. Baggy nerve root sleeves in the lower lumbar and sacral region (?? perineurial cysts).