Date : 00.00.00
Name of the Patient : Abc XyzRalmn / M / 51 yrs.
Referred by : Dr. Abc Xyzodak.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O numbness of the left foot with difficulty in holding chappals since 4 months.
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 sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
There is a postero-central disc herniation at the L1-L2 level with anterior indentation of the thecal sac. Superior migration of the disc portion is noted lying posterior to the L1 vertebral body.
A diffuse posterior disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac with bilateral neural foraminal narrowing. The L3-L4 facet joints bilaterally show hypertrophic degenerative changes.
A small posterior disc bulge is noted at the L4-L5 level.
The L2-L3 and L1-L2 intervertebral discs show loss of water content.
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
14.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
The cervical spine was screened with 4 mm thick T2 Weighted sagittal images which show posterior disc herniation at the C3-C4, C4-C5 and C5-C6 levels. If clinically indicated a dedicated study of the cervical spine would be worthwhile.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
2. A postero-central disc herniation at the L1-L2 level with superior migration of the disc portion lying posterior to the L1 vertebral body.
3. A diffuse posterior disc herniation at the L3-L4 level with hypertrophic facetal arthropathy at this level.