PROVISIONAL REPORT
Name of the Patient : Abc Xyz Galmn / F / 22 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O radicular pain in the LLE since 00.00.0000.
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 probable sacralization of the L5 vertebra which is as marked on the film. Please correlate with plain radiographs.
There is mild retroplacement of the L4 vertebra over the L5 vertebra. The L4-L5 intervertebral disc shows loss of water content.
There is a large postero-central disc extrusion compressing upon the thecal sac at the L4-L5 level. A disc portion is seen to lie within the anterior epidural space at the L5 vertebral level with resultant impingement of both the traversing L5 nerve roots.
There is a cystic lesion anterior to the right kidney (? within the liver). Further evaluation may be worthwhile (e.g.Ultrasound).
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The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
7.0 mm at L4-L5
8.0 mm at L5-S1.
IMPRESSION :
The MRI features are suggestive of :
1. Probable sacralization of the L5 vertebra which is as marked on the film. Please correlate with plain radiographs.
2. Mild retroplacement of the L4 vertebra over the L5 vertebra.
3. A large postero-central disc extrusion at the L4-L5 level with a disc portion lying within the anterior epidural space at the L5 vertebral level with resultant impingement of both the traversing L5 nerve roots and resultant canal stenosis at this level.
Please send the films back for the final report.
Thanks for the reference.