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Name of the Patient : Abc XyzShlmn / M / 35 yrs.w
Referred by : Dr. Abc Xyzwhale.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to BLE.

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 the L4-L5 and L5-S1 intervertebral discs.

There is a right postero-lateral disc herniation at the L5-S1 level with slight superior and inferior migration of the disc fragment indenting the exiting right L5 nerve root and the traversing left S1 nerve root.

Slight facetal hypertrophy is noted at this level.

There is a fairly large, posteriorly extruded disc at the L4-L5 level with inferior migration of the disc fragment compressing the thecal sac and the traversing L5 nerve roots bilaterally. Facetal hypertrophy is noted at this level, with canal stenosis.

Facetal hypertrophy is noted at the L2-L3 and L3-L4 levels.

Type II degenerative marrow changes are noted along the inferior cortical endplate of the L4 vertebral body.



The rest of the lumbar vertebral bodies and the remaining intervertebral discs 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 S2 level.

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

17.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
4.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. A right postero-lateral disc herniation at the L5-S1 level with slight superior and inferior migration of the disc fragment indenting the exiting right L5 nerve root and the traversing left S1 nerve root.

2. A fairly large, posteriorly extruded disc at the L4-L5 level with inferior migration of the disc fragment compressing the traversing L5 nerve roots bilaterally with facetal hypertrophy and canal stenosis.


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