Date : 00.00.00
Name of the Patient : Abc Xyzata Rasglmn / F / 40 yrs.
Referred by : Dr. Abc Xyznawane.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 1 month.
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 mild retrolisthesis of the L5 over S1 vertebra.
A posterior and right postero-lateral disc herniation is seen at the L5-S1 level with anterior indentation of the thecal sac and right S1 nerve root and right neural foraminal narrowing. There is suggestion of the right S1 nerve root being inflammed. This disc shows loss of water content.
A small posterior disc bulge is noted at the L4-L5 level.
The lower lumbar facet joints show mild degenerative changes.
Type II degenerative changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
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The conus medullaris terminates at the L1 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 :
18.0 mm at L1-L2
19.0 mm at L2-L3
19.0 mm at L3-L4
15.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. Mild retrolisthesis of the L5 over S1 vertebra.
2. A posterior and right postero-lateral disc herniation at the L5-S1 level with indentation on the the right S1 nerve root, which is probably inflammed.
3. A small posterior disc bulge at the L4-L5 level.