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Date : 00.00.00

Name of the Patient : Abc XyzSlmn / M / 57 yrs.
Referred by : Dr. Abc Xyzawkar / Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O radicular pain in the RLE with weakness since 1 year.
Known C/O mild anterior poliomyelitis of the RLE sinch childhood.

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 slight loss of water content of the lumbar intervertebral discs.

A minimal posterior disc bulge is noted at the L5-S1 level.

A small posterior and right postero-lateral disc bulge is noted at the L4-L5 level with minimal indentation on the extraforaminal segment of the right L4 nerve root.

The right ilio-psoas muscle is reduced in bulk when compared to the left most likely due to previous poliomyelitis.

The lumbar vertebral bodies reveal normal signal intensity. The rest of the facet joints and 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 :

16.0 mm at L1-L2

15.0 mm at L2-L3

15.0 mm at L3-L4

14.0 mm at L4-L5

9.0 mm at L5-S1.

IMPRESSION :

1. A minimal posterior disc bulge at the L5-S1 level.

2. A small posterior and right postero-lateral disc bulge at the L4-L5 level with minimal indentation on the extraforaminal segment of the right L4 nerve root.

3. The right ilio-psoas muscle is reduced in bulk when compared to the left most likely due to previous poliomyelitis.


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