Date : 00.00.00
Name of the Patient : Abc XyzBolmn / M / 36 yrs.
Referred by : Dr. Abc Xyz>
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the upper spine and BLE (on & off) with tingling in BLE since 4 years.
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.
IMAGES SHOW PATIENT MOTION.
There appears to be sacralization of the L5 vertebra and the L1 vertebra is as marked on the film.
A postero-central disc extrusion, more to the right of the midline is seen to indent the thecal sac at the L4-L5 level. There is mild facetal and ligamentum flavum hypertrophy at this level. Also seen is a left postero-lateral (foraminal) disc protrusion at this level.
A posterior disc bulge is noted at the L2-L3 level.
The L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content. Anterior disc herniations are noted at these levels.
The lumbar vertebral bodies and the remaining intervertebral discs show 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 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 :
19.0 mm at L1-L2
18.0 mm at L2-L3
15.0 mm at L3-L4
8.0 mm at L4-L5
9.0 mm at L5-S1.
The cervico-dorsal spine was screened with 4 mm T2 Weighted sagittal images and does not reveal any significant feature of note.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. A postero-central disc extrusion, more to the right of the midline with mild facetal and ligamentum flavum hypertrophy at L4-L5 level with canal stenosis at this level.