hs/ke/nl/rg.
A Date : 00.00.00
Name of the Patient : Abc Xyzhan Tholmn / M / 45 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O neckpain and backache with pain radiating to BUE and RLE with paresthesias in BUE since 1-2 years.
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 intervertebral disc shows mild loss of water content.
A large posterior disc herniation with peridiscal osteophytes is seen to indent the thecal sac and narrow both neural foramina at the L4-L5 level. The facet joints at this level show hypertrophic degenerative changes.
Ligamentum flavum hypertrophy is seen at the L4-L5 and L5 levels.
A posterior disc bulge is noted at the L5-S1 level.
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.
Scan-00000A
The conus medullaris terminates at the D12 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 :
15.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
7.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. A large posterior disc herniation with peridiscal osteophytes, hypertrophic facetal arthropathy and canal stenosis at the L4-L5 level.
2. Ligamentum flavum hypertrophy at the L4-L5 and L5 levels.