Date : 00.00.00
Name of the Patient : Abc Xyzhlmn / F / 45 yrs.
Referred by : Dr. Abc Xyztchha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since several years which has increased since 15-20 days.
H/O fall 3-4 years back.
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.
There is loss of water content of the L2-L3 to L5-S1 intervertebral discs.
There is a fairly large, right paracentral extruded disc at the L5-S1 level, indenting the traversing right S1 nerve root.
A posterior and a left far lateral disc bulge is noted at the L4-L5 level with slight bilateral neural foraminal narrowing.
A small, postero-central protruded disc is noted at the L3-L4 level.
The facet joints at the L3-L4, L4-L5 and L5-S1 levels appear slightly hypertrophied. Slight ligamentum flavum hypertrophy is also noted at the L5 vertebral level.
The lumbar vertebral bodies adjacent to the intervertebral discs show Type II degenerative marrow changes. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.
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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
15.0 mm at L3-L4
15.0 mm at L4-L5
9.0 mm at L5-S1.
1. A fairly large, right paracentral extruded disc at the L5-S1 level, indenting the traversing right S1 nerve root.
2. A posterior and a left far lateral disc bulge at the L4-L5 level.
3. A small, postero-central protruded disc at the L3-L4 level.
4. Facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels