Name of the Patient : Abc XyzChlmn / M / 47 yrs.
Referred by : Dr. Abc Xyzmbal / Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O pain in the left hip region.
Alleged H/O fall prior to this.
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 loss of water content of the L4-L5 intervertebral disc.
There is a fairly large postero-central and left paracentral extruded disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression. There is rupture of the posterior longitudinal ligament with inferior migration of the disc with indentation on the traversing left L5 nerve root. There is also facetal hypertrophy at this level with canal stenosis.
A small left postero-lateral disc bulge with peridiscal osteophytes is noted at the L5-S1 level with minimal indentation on the traversing left S1 nerve root.
Facetal hypertrophy is noted in the lumbar region.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
Perineural cysts are noted at the S1 vertebral level.
The conus medullaris terminates at the D12-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 :
18.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
1. A fairly large postero-central and left paracentral extruded disc with peridiscal osteophytes at the L4-L5 level with indentation on the traversing left L5 nerve root and facetal hypertrophy with canal stenosis.
2. A small left postero-lateral disc bulge with peridiscal osteophytes at the L5-S1 level with minimal indentation on the traversing left S1 nerve root.
3. Facetal hypertrophy in the lumbar region.
As compared to the previous MRI dated 00.00.0000, there is increase in the degree of disc herniation at L4-L5 level.