Name of the Patient : Abc XyzSlmn / M / 73 yrs.
Referred by : Dr. Abc Xyz B. Jhaveri.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain in the LLE since 00.00.0000.
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 a posterior disc herniation with left far lateral disc herniation at the L3-L4 level with anterior indentation of the thecal sac and impingement of the foraminal portion of the left L3 nerve root. Part of the disc is seen to migrate superiorly posterior to the L3 vertebra with indentation on the thecal sac laterally (Scan 106.3). The L3-L4 facet joints show hypertrophic degenerative changes.
A right paracentral disc extrusion is seen at the L1-L2 level with antero-lateral indentation of the thecal sac. Slight inferior migration of the disc fragment is noted in the right lateral recess of the L2 vertebral body.
Small posterior disc bulges with peridiscal osteophytes are noted at the L2-L3, L4-L5 and L5-S1 levels. A left far lateral disc bulge is seen at the L5-S1 level and a left postero-lateral disc bulge at the L4-L5 level.
The lumbar facet joints show degenerative changes. Anterior disc herniations are seen at the L1-L2, L2-L3, L3-L4 and L4-L5 levels.
- 2 - Scan-00003
The lumbar vertebral bodies reveal spotty fatty changes.
The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the 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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
14.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation with left far lateral disc herniation at the L3-L4 level impinging the foraminal portion of the left L3 nerve root and hypertrophic facetal arthropathy at this level.
2. A right paracentral disc extrusion at the L1-L2 level with slight inferior migration of the disc fragment in the right lateral recess of the L2 vertebral body.