Name of the Patient : Abc XyzI. Shlmn / M / 35 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating 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 evidence of a large postero-central disc extrusion compressing upon the thecal sac at the L4-L5 level. A disc portion (most likely sequestered) is seen within the anterior epidural space and right lateral recess at the L5 vertebral level. There is resultant impingement of the traversing right L5 nerve root. Also seen is slight indentation upon the traversing left L5 nerve root.
A postero-central disc herniation is seen to indent the thecal sac at the L5-S1 level.
Postero-central disc protrusions are noted at the L1-L2, L2-L3 and L3-L4 levels.
The L4-L5 facet joints show hypertrophic degenerative changes. Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels.
- 2 - Scan-00007
The L1-L2, L2-L3 and L3-L4 facet joints show degenerative changes.
The lumbar vertebral bodies 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 D12-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
14.0 mm at L2-L3
13.0 mm at L3-L4
8.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc extrusion at the L4-L5 level with a disc portion within the anterior epidural space and right lateral recess at the L5 vertebral level with impingement of the traversing right L5 nerve root.
2. A postero-central disc herniation at the L5-S1 level.
3. Hypertrophic facetal arthropathy at the L4-L5 level and
ligamentum flavum hypertrophy at the L4-L5 and L5 levels with resultant canal stenosis at these levels.