sb/ke/nl/nl
Name of the Patient : Abc Xyzriplmn / F / 50 yrs.
Referred by : Dr. Abc Xyz. Modi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) with paresthesias in the LLE.
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 loss of water content of nearly all the lumbar intervertebral discs except the L1-L2 disc with reduction in height of the L4-L5 intervertebral disc.
There is a fairly large, postero-central and left paracentral extruded disc at the L3-L4 level with thecal sac compression and indentation upon the traversing left L4 nerve root. Slight superior migration of the disc fragment is noted. Facetal hypertrophy is also noted at this level, bilaterally.
Small postero-central disc herniation is seen at the L5-S1 level minimally indenting the traversing S1 nerve roots bilaterally. Slight facetal hypertrophy is noted at this level.
A postero-central disc herniation with peridiscal osteophytes is noted at the L4-L5 level with indentation on the traversing L5 nerve roots bilaterally. Slight facetal and ligamentum flavum hypertrophy is noted at this level.
Small postero-central protruded disc is seen at the L2-L3 level.
Type II degenerative marrow changes are noted adjacent to the L4-L5 intervertebral disc.
The lumbar vertebral bodies show preponderance of hematopoeitic marrow. 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
17.0 mm at L2-L3
9.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.
IMPRESSION :
1. A fairly large, postero-central and left paracentral extruded disc at the L3-L4 level with indentation upon the traversing left L4 nerve root and facetal hypertrophy at this level, bilaterally.
2. Small postero-central disc herniation at the L5-S1 level minimally indenting the traversing S1 nerve roots bilaterally and slight facetal hypertrophy at this level.
..3/.
- 3 - Scan-00007
3. A postero-central disc herniation with peridiscal osteophytes at the L4-L5 level with indentation on the traversing L5 nerve roots bilaterally. Slight facetal and ligamentum flavum hypertrophy is noted at this level.
4. Small postero-central protruded disc at the L2-L3 level.
5. Lumbar canal stenosis at the L3-L4 and L5-S1 levels.