Name of the Patient : Abc Xyz Chakrablmn / M / 29 yrs.
Referred by : Dr. Abc Xyzeshattiwar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with tingling.
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 L4-L5 and L5-S1 intervertebral discs show loss of water content.
There is a large postero-central disc extrusion indenting the thecal sac at the L4-L5 level. A disc portion is seen to lie within the left lateral recess of the L5 vertebra with resultant impingement of the traversing left L5 nerve root.
A small right paracentral disc herniation is noted at the L5-S1 level. Bilateral far lateral disc bulges are also seen at this level.
The facet joints over the L1-L2 to the L4-L5 level show mild degenerative changes.
Small posterior peridiscal osteophytes are seen at the L4-L5 and L5-S1 levels.
Type II degenerative changes are noted within the superior aspect of the L5 and S1 vertebral bodies.
There is an anterior disc herniation with peridiscal osteophytes at the L4-L5 level.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
19.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
6.0 mm at L4-L5
11.0 mm at L5-S1.
1. A large postero-central disc extrusion at the L4-L5 level with a disc portion lying within the left lateral recess of the L5 vertebra with resultant impingement of the traversing left L5 nerve root.
2. A small right paracentral disc herniation at the L5-S1 level.
3. Mild facetal arthropathy over the L1-L2 to the L4-L5 level.