Date : 00.00.00
Name of the Patient : Abc Xyznd Jolmn / M / 78 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) with numbness since 1 1/2 months.
Alleged H/O fall 4 months back.
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.
The lumbar intervertebral discs show loss of water content.
There is a large postero-central disc herniation at the L5-S1 level with anterior compression of the thecal sac, bilateral neural foraminal narrowing and canal stenosis. There is superior migration of the disc which is seen to lie in the right lateral recess of the L5 vertebral body, impinging the traversing right L5 nerve root. The L5-S1 facet joints show hypertrophic degenerative changes. Mild ligamentum flavum hypertrophy is also noted at this level with canal stenosis.
Bilateral postero-lateral disc bulges are seen at the L1-L2, L2-L3, L3-L4 and L4-L5 levels with bilateral neural foraminal narrowing. The facet joints at these levels show degenerative changes.
A probable conjoint nerve root is identified on the right side at the S2 level.
- 2 - Scan-00006
There is forward translation of the L2 over the L3 vertebral body. Anterior disc herniations are seen at the D11-D12, L1-L2, L2-L3 and L5-S1 levels.
The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
The lumbar vertebral bodies reveal normal signal intensity. 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 :
14.0 mm at L1-L2
11.0 mm at L2-L3
14.0 mm at L3-L4
16.0 mm at L4-L5
8.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc herniation at the L5-S1 level with superior migration of the disc in the right lateral recess of the L5 with impingement of the traversing right L5 nerve root with hypertrophic facetal arthropathy and mild ligamentum flavum hypertrophy and canal stenosis at this level.
2. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.
3. Bilateral postero-lateral disc bulges at the L1-L2, L2-L3, L3-L4 and L4-L5 levels with facetal hypertrophy at these levels.