Name of the Patient : Abc Xyzlmn / F / 33 yrs.
Referred by : Dr. Abc Xyzansali.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) with paresthesias.
H/O Cervical lymphadenopathy 5 years ago. Received AKT.
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 L2 vertebra is as marked on the film.
There is slight straightening of the lumbar spine and loss of water content of the lumbar intervertebral discs.
There is slight retroplacement of the L3 over the L4 vertebral body with a large posterior disc herniation with peridiscal osteophytes at the L3-L4 level compressing the thecal sac with resultant canal stenosis. Inferior migration of the disc is noted lying posterior to the L4 vertebral body and impinging the traversing L4 nerve roots, left more than right. The L3-L4 facet joints show mild degenerative changes.
There are small posterior disc herniations at the D11-D12, D12-L1, L1-L2, L2-L3 and the L4-L5 levels with bilateral far lateral disc bulges at the L4-L5 level.
The pedicles of the lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
- 2 - Scan-00001
Anterior disc herniations are noted at the D11-D12 and L1-L2
levels. Slight anterior wedging of the D11 and D12 vertebral body is seen without any signal change. Type II degenerative changes are seen in the L4 and L5 vertebral bodies adjacent to the L4-L5 intervertebral disc.
The lumbar facet joints show mild degenerative changes.
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-L2 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 :
13.0 mm at L1-L2
13.0 mm at L2-L3
9.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.
Screening of the sacro-iliac joints reveals no feature of note.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. Slight retroplacement of the L3 over the L4 vertebral body.
3. A large posterior disc herniation with peridiscal osteophytes with resultant canal stenosis at the L3-L4 level with inferior migration of the disc lying posterior to the L4 vertebral body and impinging the traversing L4 nerve roots (left more than right).
- 3 - Scan-00001
4. Small posterior disc herniations at the D11-D12, D12-L1, L1-L2, L2-L3 and the L4-L5 levels.
5. Congenitally short pedicles in their antero-posterior dimensions.
6. Mild facetal arthropathy in the lumbar region.