Date : 00.00.00
Name of the Patient : Abc Xyzabhaga C. Salmn / F / 58 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Dorso-lumbar Spine.
CLINICAL PROFILE :
C/O right sided backache since 2 months.
M.R.I of the dorso-lumbar 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.
A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. Small far lateral disc herniations are seen bilaterally at this level.
A small right postero-lateral disc herniation is seen to narrow the right neural foramen at the L3-L4 level. Left far lateral disc protrusion is seen to indent the exiting left L3 nerve root at the L3-L4 level.
There is a posterior disc bulge at the L5-S1 level. Bilateral far lateral disc bulges are noted at this level.
Facetal and ligamentum flavum hypertrophy is noted at the L4-L5 and L5-S1 levels.
The visualized dorso-lumbar intervertebral discs show loss of water content. The visualized dorso-lumbar vertebral bodies show normal signal intensity.
The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The visualized lower dorsal spinal cord reveals normal signal intensity.
The cervico-dorsal spine was screened with 4 mm thick T1 Weighted sagittal images and does not show any significant feature of note.
The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the dorso-lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
13.0 mm at L4-L5
14.0 mm at L5-S1.
The MRI features are suggestive of :
1. Small posterior and far lateral disc herniations at the L4-L5 level.
2. A small right postero-lateral disc herniation and a left far lateral disc protrusion at the L3-L4 level.
3. Facetal and ligamentum flavum hypertrophy at the L4-L5 and L5-S1 levels.
4. Canal stenosis at the L4-L5 level.