sb/bv/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzh Shlmn / M / 48 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 2 1/2 months. Also C/O difficulty in passing urine since 1 1/2 months.
EXAMINATION :
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.
OBSERVATION :
There is loss of normal lumbar lordosis and loss of water content of all the lumbar intervertebral discs, except the L5-S1 disc. There is clockwise rotation of the upper lumbar vertebrae and scoliosis of the lumbar spine with convexity to the left side.
There is a fairly large posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression and indentation on the traversing L5 nerve roots bilaterally. Slight superior migration of the disc is noted.
A postero-central disc herniation with peridiscal osteophytes is noted at the L3-L4 level with slight left neural foraminal narrowing.
Small postero-central protruded disc with peridiscal osteophytes is noted at the L2-L3 level.
A left postero-lateral disc herniation with peridiscal osteophytes is noted at the L1-L2 level with left neural foraminal narrowing.
The facet joints over the L1-L2 to the L4-L5 levels show degenerative changes bilaterally, more so on the left side.
The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
Incidentally noted is a fat in the filum terminale over L2 to L5 vertebral levels.
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 :
13.0 mm at L1-L2
13.0 mm at L2-L3
14.0 mm at L3-L4
9.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. A fairly large posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level with indentation on the traversing L5 nerve roots bilaterally.
2. A postero-central disc herniation with peridiscal osteophytes at the L3-L4 level with slight left neural foraminal narrowing.
..3/.
- 3 - Scan-00007
3. Small postero-central protruded disc with peridiscal osteophytes at the L2-L3 level.
4. A left postero-lateral disc herniation with peridiscal osteophytes at the L1-L2 level with left neural foraminal narrowing.
5. Facetal arthropathy over the L1-L2 to the L4-L5 levels.
6. Tight lumbar canal at the L2-L3 and L3-L4 and severe canal stenosis at the L4-L5 level.
As compared to the previous MRI dated 00.00.00, there is no significant change noted.