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Name of the Patient : Abc XyzPlmn / M / 58 yrs.
Referred by : Dr. Abc Xyzolakia.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O pain in the left buttock with radiation of pain to the LLE.

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 show loss of water content.

A posterior disc herniation more to the left of the midline is seen to indent the thecal sac and the traversing left L5 nerve root and narrow both neural foramina at the L4-L5 level.

A small postero-central disc herniation is seen to indent the thecal sac at the L3-L4 level.

Posterior disc bulges are noted at the L2-L3 and L5-S1 levels. Small posterior peridiscal osteophytes are seen at the L3-L4, L4-L5 and L5-S1 levels.

Facetal hypertrophy is seen over the L2-L3 to L5-S1 levels.

Far lateral disc bulges are noted over the L2-L3 to L4-L5 levels.



The pedicles of the lumbar vertebrae are congenitally short in their antero-posterior dimensions.

There is an anterior disc herniation with peridiscal osteophytes at the L1-L2 level.

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 D12-L1 level and the thecal sac terminates at the S1 level.

The dorsal spine was screened with 4 mm thick T1 Weighted sagittal images and shows narrowing of the D3-D4 disc space. The vertebrae however show normal signal intensity.

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

17.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
12.0 mm at L5-S1.

IMPRESSION :

The MRI features are suggestive of :

1. A posterior disc herniation, more to the left of the midline with a tight canal at the L4-L5 level.

2. A small postero-central disc herniation at the L3-L4 level.
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3. Facetal hypertrophy over the L2-L3 to L5-S1 levels.

4. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.

As compared to the previous MRI dated 00.00.00, there is slight increase in the disc herniation at the L4-l5 and L3-L4 levels. The previously identified tuberculous infection in the dorsal area at the D3 and D4 levels shows evidence of healing.

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