hs/ke/rg.
Date : 00.00.00
Name of the Patient : Abc XyzSlmn / F / 41 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias.
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 appears to be sacralization of the L5 vertebra and the L1 vertebra is as marked on the film.
A large left paracentral disc extrusion is seen to indent the thecal sac at the L4-L5 level. A disc portion is seen to lie within the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root. Large left postero-lateral (foraminal) and far lateral (extraforaminal) disc extrusions are seen at this level with left neural foraminal narrowing and indentation upon the exiting left L4 nerve root.
The L4-L5 intervertebral disc shows loss of water content.
The L3-L4 and L4-L5 facet joints show degenerative changes.
Type II degenerative changes are seen in the superior aspect of the L5 vertebral body.
The rest of 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.
..2/.
The conus medullaris terminates at the D11-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 :
20.0 mm at L1-L2
19.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. A large left paracentral disc extrusion
at the L4-L5 level with a disc portion seen to lie within the left lateral recess of the L5 vertebra with impingement of the traversing left L5 nerve root.
3. Large left postero-lateral (foraminal) and far lateral (extraforaminal) disc extrusions at the L4-L5 level with indentation upon the exiting left L4 nerve root.