Name of the Patient : Abc Xyz. Paidhulmn / F / 55 yrs.
Referred by : Dr. Abc Xyzidhungat.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias.
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.
There is sacralization of the L5 vertebra and the L3 vertebral body is as marked on the film.
There is loss of water content of the lumbar intervertebral discs.
There is minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
A small posterior disc bulge is noted at the L4-L5 level with slight bilateral neural foraminal narrowing. Far lateral disc bulges are identified at the L4-L5 level with indentation upon the extraforaminal L4 nerve roots. There is also hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with resultant lateral recess stenosis, bilaterally at the L4-L5 level. Bilateral facet joint effusion is noted at the L4-L5 level.
Slight facetal and ligamentum flavum hypertrophy is noted at the L3-L4 level.
Type II degenerative marrow changes are noted adjacent to the L4-L5 disc.
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 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
21.0 mm at L2-L3
19.0 mm at L3-L4
14.0 mm at L4-L5
11.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. Minimal forward translation of the L4 over the L5 vertebra without obvious spondylolysis.
3. A small posterior disc bulge at the L4-L5 level with far lateral disc bulges at this level indenting the extraforaminal L4 nerve roots with slight bilateral neural foraminal narrowing, hypertrophic facetal arthropathy and ligamentum flavum hypertrophy with resultant lateral recess stenosis, bilaterally. Bilateral facet joint effusion is noted at the L4-L5 level.