Name of the Patient : Abc Xyzlmn / F / 50 yrs.
Referred by : Dr. Abc Xyzhah / Dr. Abc Xyzhta.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain to the LLE 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.
The lumbar intervertebral discs show loss of water content.
There is slight anterior wedging of the L1 vertebral body with fatty marrow changes within it.
A large left paracentral disc extrusion is seen to indent the thecal sac and narrow the left neural foramen at the L5-S1 level. A disc portion is seen to lie within the left lateral recess of the S1 vertebra with resultant impingement of the traversing left S1 nerve root.
A small posterior disc herniation is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level.
A small postero-central disc herniation is seen to indent the thecal sac at the L2-L3 level.
There is a posterior disc bulge indenting the thecal sac and narrowing both neural foramina at the L3-L4 level.
Bilateral far lateral disc bulges are noted over the L2-L3 to L5-S1 levels.
The lumbar facet joints show degenerative changes with facetal hypertrophy at the L4-L5 and L5-S1 levels.
A focal area of hyperintensity on all the pulse sequences is seen within the L2 vertebral body on the right side and may represent a hemangioma with fat content. Type II degenerative changes are seen within the lumbar vertebral bodies and within the S1 vertebral body adjacent to the L5-S1 intervertebral disc.
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 S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.
1. A large left paracentral disc extrusion at the L5-S1 level with a disc portion lying within the left lateral recess of the S1 vertebra with resultant impingement of the traversing left S1 nerve root.
2. A small posterior disc herniation at the L4-L5 level.
3. A small postero-central disc herniation at the L2-L3 level.
4. Facetal arthropathy in the lumbar region with hypertrophic changes at the L4-L5 and L5-S1 levels.