hs/sb/nl/rg.
Name of the Patient : Abc XyzM. Shlmn / M / 42 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain with paresthesias and weakness in BLE.
Alleged H/O fall 2 months ago.
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 normal lumbar lordosis. The L4-L5 and L5-S1 intervertebral discs show loss of water content.
There is slight clockwise rotation of the lumbar vertebral bodies.
A left postero-lateral and left far lateral disc herniation is seen to narrow the left neural foramen and indent the exiting left L4 nerve root at the L4-L5 level.
Posteriorly bulging discs with peridiscal osteophytes are seen to indent the thecal sac at the L3-L4, L4-L5 and L5-S1 levels.
The L4-L5 facet joints show degenerative changes.
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.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.0 mm at L1-L2
16.0 mm at L2-L3
13.0 mm at L3-L4
15.0 mm at L4-L5
15.0 mm at L5-S1.
Screening, T2 Weighted sagittal images of the dorsal spine reveal a small postero-central protruded disc at the D7-D8 level.
IMPRESSION :
The MRI features are suggestive of :
1. Left postero-lateral and left far lateral disc herniations indenting the exiting left L4 nerve root at the L4-L5 level.
2. Facetal arthropathy at the L4-L5 level.
3. Posteriorly bulging discs with peridiscal osteophytes at the L3-L4, L4-L5 and L5-S1 levels.