Name of the Patient : Abc Xyzree J. Malmn / F / 55 yrs.
Referred by : Dr. Abc Xyzraf.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 2 months.
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 loss of normal lumbar lordosis and the lumbar intervertebral discs show loss of water content. The L2-L3, L3-L4 and L4-L5 intervertebral discs are decreased in height.
There is a posterior disc extrusion with peridiscal osteophyes compressing upon the thecal sac and narrowing both neural foramina at the L3-L4 level with resultant significant canal stenosis.
A posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.
Small posterior disc herniations are seen to indent the thecal sac and cause mild bilateral neural foraminal narrowing at the L2-L3 and L5-S1 levels.
There are small posterior peridiscal osteophytes at the L2-L3, L4-L5 and L5-S1 levels.
Small, postero-lateral disc bulges are noted bilaterally at the L1-L2 level. Bilateral far lateral disc bulges are seen over the L2-L3 to the L5-S1 levels.
The lumbar facet joints show mild degenerative changes. The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
There appears to be a spina bifida at the S1 level.
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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
13.0 mm at L2-L3
5.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
1. A posterior disc extrusion with peridiscal osteophytes at the L3-L4 level with resultant canal stenosis.
2. A posterior disc herniation at the L4-L5 level.
3. Small posterior disc herniations at the L2-L3 and L5-S1
4. Posterior peridiscal osteophytes at the L2-L3, L4-L5 and L5-S1 levels.
5. Mild facetal arthropathy in the lumbar region.
6. Congenitally short pedicles of the lumbar vertebrae in their antero-posterior dimensions.