hs/ke/rg/nl
A
Name of the Patient : Abc Xyz lmn / F / 58 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O pain in the entire back, radiating to the LLE and BUE with paresthesias in BUE since 4 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 mild retroplacement of the L2 over the L3, L3 over the L4, L4 over the L5 and L5 over the S1 vertebrae. The lumbar intervertebral discs show loss of water content. The D11-D12, L2-L3 and L5-S1 intervertebral discs are decreased in height and show areas of calcium/vacuum phenomena.
A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L5-S1 level. A disc portion is seen to lie within the left lateral recess of the S1 vertebra with impingement of the traversing left S1 nerve root.
A posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.
There is a small posterior disc herniation with large peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina at the L3-L4 level.
..2/.
- 2 - Scan-00009A
Also seen is a small posterior disc herniation with small peridiscal osteophytes indenting the thecal sac and narrowing both neural foramina at the L2-L3 level.
Bilateral far lateral disc herniations are noted at the L5-S1 level. Bilateral far lateral disc bulges are seen at the L2-L3, L3-L4 and L4-L5 levels.
Facetal hypertrophy is seen at the L3-L4, L4-L5 and L5-S1 levels. Ligamentum flavum hypertrophy is noted at the L4-L5 level.
The lumbar vertebral bodies show Type II degenerative/ spotty fatty marrow changes.
The visualized pre and paravertebral soft tissues are unremarkable.
The dorsal spine was screened with 4 mm thick T1 Weighted sagittal images and does not show any significant feature of note.
The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2-S3 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
11.0 mm at L2-L3
9.0 mm at L3-L4
11.0 mm at L4-L5
8.0 mm at L5-S1.
- 3 - Scan-00009A
IMPRESSION :
The MRI features are suggestive of :
1. A posterior disc herniation with peridiscal osteophytes at the L5-S1 level with a disc portion lying within the left lateral recess of the S1 vertebra with impingement of the traversing left S1 nerve root.
2. A posterior disc herniation with peridiscal osteophytes at the L4-L5 level.
3. A small posterior disc herniation with large peridiscal osteophytes at the L3-L4 level.
4. A small posterior disc herniation with small peridiscal osteophytes at the L2-L3 level.
5. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels and ligamentum flavum hypertrophy at the L4-L5 level.
6. Canal stenosis at the L5-S1 level and a tight canal at the L3-L4 and L4-L5 levels.