Name of the Patient : Abc Xyzr Nlmn / M / 45 yrs.
Referred by : Dr. Abc Xyzapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with numbness.
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.
There appears to be sacralization of the L5 vertebra and the D12 vertebra is as marked on the film. Please correlate with plain radiographs.
A posterior disc herniation with peridiscal osteophytes, more to the right of the midline is seen to indent the thecal sac and cause mild bilateral neural foraminal narrowing at the L4-L5 level. A small disc portion is seen to lie within the anterior epidural space with indentation on both the traversing L5 nerve roots. A very small disc portion is seen to lie within the left anterior epidural space at the L4 vertebral level.
There is facetal hypertrophy at the L2-L3, L3-L4 and L4-L5 levels. Mild ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels. Also seen is mild facetal hypertrophy at the L1-L2 level.
There is a mild posterior disc bulge at the L2-L3 level. Bilateral far lateral disc bulges are noted at the L4-L5 level.
The L4-L5 intervertebral disc shows loss of water content. Type II degenerative changes are noted within the superior aspect of the L5 vertebral body adjacent to the L4-L5 disc.
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
20.0 mm at L2-L3
18.0 mm at L3-L4
16.0 mm at L4-L5
13.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A posterior disc herniation, more to the right of the midline at the L4-L5 level with a small disc portion lying within the anterior epidural space indenting both the traversing L5 nerve roots.
3. Facetal hypertrophy at the L2-L3, L3-L4 and L4-L5 levels with mild ligamentum flavum hypertrophy at the L4-L5 and L5 levels.