hs/bv/rg/nl

Name of the Patient : Abc XyzTilmn / F / 57 yrs.
Referred by : Dr. Abc Xyziwari.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias since 3 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 :

The lumbar intervertebral discs except at the L1-L2 level show loss of water content.

There is evidence of a large right far lateral disc extrusion at the L4-L5 level. An extruded disc portion is seen to lie within the soft tissues lateral to the right neural foramen with indentation upon the exiting right L4 nerve root at this level.

A left far lateral disc herniation is seen to indent the exiting left L3 nerve root at the L3-L4 level.

Small postero-central disc herniations with peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels.

The L5-S1 facet joints show mild degenerative changes.

Type II degenerative changes are noted within the antero-superior aspect of the L4 and L5 vertebral bodies.

There is slight atrophy of the paraspinal muscles in the lumbo-sacral region.
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The rest of the lumbar vertebral bodies 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-L2 level and the thecal sac terminates at the S1-S2 level.

The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

16.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A large right far lateral disc extrusion at the L4-L5 level with an extruded disc portion lying within the soft tissues lateral to the right neural foramen with indentation upon the exiting right L4 nerve root at this level.

2. A left far lateral disc herniation indenting the exiting left L3 nerve root at the L3-L4 level.

3. Small postero-central disc herniations with peridiscal osteophytes at the L4-L5 and L5-S1 levels.