Date : 00.00.00
Name of the Patient : Abc Xyz Gulmn / M / 53 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to 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 loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
There is a fairly large, postero-central disc herniation at the L4-L5 level with thecal sac compression. Hypertrophic facetal arthropathy is also noted at this level, with resultant canal stenosis.
A left postero-lateral (foraminal) disc herniation is noted at the L5-S1 level indenting the left L5 nerve root.
A small posterior peridiscal osteophyte is noted at the L3-L4 level.
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 :
19.0 mm at L1-L2
20.0 mm at L2-L3
20.0 mm at L3-L4
7.0 mm at L4-L5
12.0 mm at L5-S1.
The dorsal spine was screened with 4 mm thick T1 Weighted sagittal images and 5 mm thick T2 Weighted axial images.
There is slight widening of the spinal canal at the D11 and D12 vertebral levels. There is seen a lobulated, extradural, CSF intensity lesion on all the pulse sequences in the left lateral and posterior epidural space over the D10 to L1 vertebral levels. The lesion is seen to extend into the left neural foramen at the D10-D11, D11-D12 and D12-L1 levels. There is resultant mild compression and displacement of the lower dorsal spinal cord to the right over the D10 to D12 vertebral levels. The lower dorsal spinal cord however shows normal signal intensity.
1. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
2. A fairly large, postero-central disc herniation at the L4-L5 level with hypertrophic facetal arthropathy and resultant canal stenosis.
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3. A left postero-lateral (foraminal) disc herniation at the L5-S1 level indenting the left L5 nerve root.
4. An extradural CSF intensity lesion on all the pulse sequences in the left lateral and posterior epidural space over the D10 to L1 vertebral levels with slight widening of the spinal canal at the D11 and D12 vertebral levels as described, most likely represents a perineurial/arachnoid cyst. There is resultant mild cord compression at the D11 and D12 vertebral levels without altered signal of the lower dorsal spinal cord.