Name of the Patient : Abc Xyz C. lmn / F / 50 yrs.
Referred by : Dr. Abc Xyzrani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with tingling in left foot.
H/O right mastectomy done in 0000. Received Chemotherapy (6 cycles).
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 except for the L5-S1 disc show loss of water content.
There is slight forward translation of the L4 over the L5 vertebral body without any spondylolysis. There appears to be partial sacralization of L5 on the left.
A postero-central disc herniation is seen at the L4-L5 level more to the left of the midline with anterior indentation of the thecal sac. The L4-L5 facet joints show mild degenerative changes, with effusion within the right facet joint.
A left far lateral (foraminal) disc herniation is seen at the L3-L4 level.
Small postero-central disc herniations are noted at the L1-L2 and L2-L3 levels.
- 2 - Scan-00009
There are anterior disc herniations at the L2-L3 and L4-L5 levels. Type I degenerative changes are noted in the L2 and L3 vertebral bodies adjacent to the L2-L3 intervertebral disc.
The lumbar facet joints show degenerative changes.
Fat is noted in the filum terminale over the L1 to the L3 vertebral levels.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 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 :
21.0 mm at L1-L2
18.0 mm at L2-L3
19.0 mm at L3-L4
13.0 mm at L4-L5
15.0 mm at L5-S1.
The right kidney appears smaller in size and requires further evaluation.
The dorsal spine was screened with 5 mm thick T1 Weighted sagittal images and shows no feature of note.
The MRI features are suggestive of :
1. Slight forward translation of the L4 over the L5 vertebral body without any spondylolysis.
- 3 - Scan-00009
2. A postero-central disc herniation at the L4-L5 level.
3. A left far lateral (foraminal) disc herniation at the L3-L4 level.
4. Small postero-central disc herniations at the L1-L2 and L2-L3 levels.
5. Facetal arthropathy in the lumbar region.