Date : 00.00.00
Name of the Patient : Abc Xyzp Slmn / M / 38 yrs.
Referred by : Dr. Abc Xyzdi / Dr. Abc Xyzoshi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain in BLE 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 large postero-central disc extrusion, more to the left of the midline at the L5-S1 level with severe compression of the thecal sac, canal stenosis and left neural foraminal narrowing. There is superior migration of the disc at the L5 level. There is impingement of the traversing S1 nerve roots, left more than right. The L5-S1 facet joints show mild degenerative changes. A left far lateral (extraforaminal) disc bulge is noted at the L5-S1 level.
A right paracentral disc herniation is noted at the L4-L5 level with indentation upon the thecal sac and slight right neural foraminal narrowing. Facetal hypertrophy is seen at this level.
A postero-central disc herniation is seen at the L3-L4 level with indentation upon the thecal sac. Facetal hypertrophy is also seen at this level.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
Type II degenerative changes are seen in the L5 and S1 vertebral bodies 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 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
13.0 mm at L3-L4
12.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc extrusion, more to the left of the midline at the L5-S1 level with canal stenosis. There is superior migration of the disc at the L5 level. There is impingement of the traversing S1 nerve roots, left more than right.
2. A right paracentral disc herniation at the L4-L5 level.
3. A postero-central disc herniation at the L3-L4 level.
4. Mild facetal arthropathy at the L5-S1 level.