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Name of the Patient : Abc Xyzo Virlmn / M / 35 yrs.
Referred by : Dr. Abc Xyzingh.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O backache with pain radiating to the RLE with paresthesias.

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 right paracentral disc extrusion with peridiscal osteophytes at the L5-S1 level with right antero-lateral indentation of the thecal sac, right neural foraminal narrowing and impingement of the traversing right S1 nerve root. Slight superior migration of the disc is seen with impingement of the right L5 nerve root. The L5-S1 facet joints show hypertrophic degenerative changes with slight ligamentum flavum hypertrophy at the L5 level.

A small left far lateral disc herniation is seen at the L4-L5 level.

The L2-L3, L3-L4 and L4-L5 facet joints also show hypertrophic degenerative changes.

Right far lateral disc bulges are noted over the L1-L2 to L5-S1 levels.

The L4-L5 and L5-S1 intervertebral discs show loss of water content.

The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and 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 :

20.0 mm at L1-L2
19.0 mm at L2-L3
18.0 mm at L3-L4
14.0 mm at L4-L5
10.0 mm at L5-S1.

IMPRESSION :

1. A right paracentral disc extrusion with peridiscal osteophytes and impingement of the traversing right S1 nerve root at the L5-S1 level. There is slight superior migration of the disc with impingement of the right L5 nerve root.

2. A small left far lateral disc herniation at the L4-L5 level.

3. Hypertrophic facetal arthropathy at the L5-S1 level with ligamentum flavum hypertrophy at the L5 level.

4. Hypertrophic facetal arthropathy at the L2-L3, L3-L4 and L4-L5 levels.


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