ke/sb/rg/nl
Name of the Patient : Abc Xyzar S. Salmn / M / 60 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 15-20 days.
EXAMINATION :
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.
OBSERVATION :
There is a slight forward translation of the L4 over the L5 vertebral body without obvious spondylolysis.
A large posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. Bilateral far lateral disc herniations are also noted at this level with indentation upon the foraminal and the extraforaminal portion of the left L4 nerve root. The L4-L5 facet joints show degenerative changes with mild ligamentum flavum hypertrophy and resultant canal stenosis.
A large postero-central disc extrusion with posterior peridiscal osteophytes is seen at the L2-L3 level with anterior indentation of the thecal sac. Slight superior migration of the disc is noted.
A diffuse posterior disc herniation is seen at the L3-L4 level. A right postero-lateral and right far lateral disc herniation is also noted at this level with right neural foraminal narrowing.
..2/.
- 2 - Scan-00001
A small posterior disc herniation is noted at the L5-S1 level.
The lumbar intervertebral discs show loss of water content.
The lumbar vertebral bodies reveal normal signal intensity. The facet joints at the L2-L3, L3-L4 and L5-S1 levels appear slightly hypertrophied. 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
9.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
IMPRESSION :
1. Slight forward translation of the L4 over the L5 vertebral body without obvious spondylolysis.
2. A large posterior disc herniation at the L4-L5 level with indentation upon the foraminal and the extraforaminal portion of the left L4 nerve root. There is facetal arthropathy with mild ligamentum flavum hypertrophy and resultant canal stenosis at this level.
3. A large postero-central disc extrusion with posterior peridiscal osteophytes at the L2-L3 level with slight superior migration of the disc.
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- 3 - Scan-00001
4. A diffuse posterior and right postero-lateral disc herniation at the L3-L4 level.
5. A small posterior disc herniation at the L5-S1 level.