sb/ke/rg/nl
Name of the Patient : Abc XyzAl-Balmn / F / 45 yrs.
Referred by : Dr. Abc Xyzolakia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 7 months.
Alleged H/O fall prior to this.
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 the L3-L4 and L4-L5 intervertebral discs.
There is a small, postero-central protruded disc at the L5-S1 level with slight facetal hypertrophy at this level.
Fairly large, posteriorly herniated disc with peridiscal osteophytes are noted at the L3-L4 and L4-L5 levels (the larger one at the L3-L4 level) with thecal sac compression and bilateral nerual foraminal narrowing. There is indentation on the traversing L4 and L5 nerve roots bilaterally. Slight facetal hypertrophy is also noted at these levels, more so at the L3-L4 level.
Facetal hypertrophy is also noted at the L1-L2 and L2-L3 levels.
Scan-00000
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 L2 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 :
14.0 mm at L1-L2
14.0 mm at L2-L3
8.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.
IMPRESSION :
1. Degenerated L3-L4 and L4-L5 intervertebral discs with fairly large, posteriorly herniated discs with peridiscal osteophytes at these levels (the larger one being at the L3-L4 level) with facetal hypertrophy and canal stenosis.
2. A small, postero-central protruded disc at the L5-S1 level with slight facetal hypertrophy at this level.