Date : 00.00.00
Name of the Patient : Abc Xyzshna Kalmn / M / 30 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 LLE with paresthesias with foot drop since 15 days.
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 mild retroplacement of the L5 vertebra over the S1 vertebra.
There is a right paracentral and right postero-lateral disc herniation at the L4-L5 level with compression upon the thecal sac and right neural foraminal narrowing. Slight inferior migration of the disc is seen with indentation upon both the traversing L5 nerve roots. Small posterior peridiscal osteophytes are also seen at this level.
A small posterior disc herniation with peridiscal osteophytes is seen at the L5-S1 level.
A postero-central disc protrusion is noted at the L1-L2 level.
A right far lateral (extraforaminal) disc herniation is seen at the L4-L5 level.
- 2 - Scan-00002
The L1-L2, L4-L5 and L5-S1 intervertebral discs show loss of water content.
The L4-L5 facet joints show hypertrophic degenerative changes. Facetal hypertrophy is seen at the L5-S1 level.
Type II degenerative changes are seen within the S1 vertebral body adjacent to the L5-S1 intervertebral disc.
The rest of 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-L2 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 :
13.0 mm at L1-L2
16.0 mm at L2-L3
18.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
The MRI features are suggestive of :
1. A right paracentral and right postero-lateral disc herniation with posterior peridiscal osteophytes at the L4-L5 level. There is slight inferior migration of the disc with indentation upon both the traversing L5 nerve roots.
2. A small posterior disc herniation with peridiscal osteophytes at the L5-S1 level. Facetal hypertrophy is also seen at this level.
3. Hypertrophic facetal arthropathy at the L4-L5 level with resultant canal stenosis.