Name of the Patient : Abc Xyz Shlmn / M / 32 yrs.
Referred by : Dr. Abc Xyzance Nursing Home.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with paresthesias in the RUE and RLE.
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 :
The L5 vertebra is as marked on the film. Please correlate with plain radiographs.
Mild retroplacement of the L4 vertebra over the L5 vertebra is noted.
The L4-L5 intervertebral disc shows loss of water content.
A postero-central disc herniation with peridiscal osteophytes is seen to indent the thecal sac at the L4-L5 level. There is slight inferior migration of this disc with indentation upon the traversing L5 nerve roots.
There is a mild posterior disc bulge at the L5-S1 level.
Far lateral disc bulges are seen bilaterally at the L3-L4 and L4-L5 levels and on the left side at the L5-S1 level. A minimal posterior disc bulge is seen at the L3-L4 level.
There is facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels. Ligamentum flavum hypertrophy is noted at the L4-L5 and L5 levels with a resultant tight canal.
The lumbar vertebral bodies appear more hypointense than normal on the T1 Weighted images and this may reflect a preponderance of hematopoeitic marrow.
The lumbar intrathecal nerve roots appears slightly clumped together.
The remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12-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 :
15.0 mm at L1-L2
14.0 mm at L2-L3
11.0 mm at L3-L4
7.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
1. A postero-central disc herniation with peridiscal osteophytes, slight inferior migration of this disc indenting upon the traversing L5 nerve roots at the L4-L5 level.
2. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels.
3. Ligamentum flavum hypertrophy at the L4-L5 and L5 levels with a resultant tight canal.
4. Clumped lumbar intrathecal nerve roots (?? arachnoiditis).