MRI Report

MRI Report: Clinical Information: - Suspected spinal pathology: Patient presents with progressive lower back pain radiating to both legs, associated with bilateral lower limb weakness and numbness for the past three months. Clinical examination revealed sensory deficit in L4-S1 dermatomes and reduced ankle reflexes bilaterally. Referrer suspects lumbar disc herniation with possible spinal cord compression. - Relevant medical history includes a previous episode of mild lower back pain managed conservatively five years prior. No history of trauma or neurosurgery. Patient has well-controlled hypertension and denies any history of tuberculosis or HIV. Current medications include lisinopril and ibuprofen as needed. Findings: - Lumbar spine MRI demonstrates a large central and right paracentral disc extrusion at the L4-L5 level, significantly impinging upon the thecal sac and compressing the exiting right L5 nerve root. There is associated oedema in the posterior longitudinal ligament and disc space. Mild degenerative changes are noted at L3-L4 and L5-S1 levels, including disc desiccation and minor facet arthropathy, but without significant canal stenosis. No vertebral body collapse or abnormal signal within the vertebral bodies. The conus medullaris appears unremarkable and terminates at the L1 level. No meningeal enhancement or evidence of intramedullary lesions. Impression: - Large L4-L5 central and right paracentral disc extrusion causing significant spinal canal stenosis and right L5 nerve root compression. Findings are consistent with the patient's clinical presentation of radiculopathy. Recommendations: - Neurosurgical referral for assessment and consideration of surgical intervention due to the severity of compression and neurological deficits. Correlation with patient's clinical symptoms is advised. No further imaging recommended at this time. Radiologist: - Dr. A. Van Der Merwe, MMed Rad (D) - [Radiologist’s Digital Attestation] - 01/11/2024