Date : 00.00.00
Name of the Patient : Abc Xyzelmn / M / 31 yrs.
Referred by : Dr. Abc Xyzddiqui.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 4 days.
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 normal lumbar lordosis and loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is a fairly large, postero-central and right paracentral extruded disc at the L5-S1 level indenting the traversing right S1 nerve root. A sequestered disc fragment is noted in the right lateral recess of S1. Bilateral far lateral disc herniations are also noted at this level with indentation upon the extraforaminal portion of the exiting L5 nerve roots at this level.
A postero-central and left paracentral disc herniation is noted at the L4-L5 level with slight left neural foraminal narrowing.
Posterior peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels.
Type II degenerative marrow changes are noted adjacent to the L5-S1 disc. The L5-S1 facet joints show degenerative changes.
Scan - 00003
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
17.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
11.0 mm at L5-S1.
1. A fairly large, postero-central and right paracentral extruded disc at the L5-S1 level indenting the traversing right S1 nerve root. A sequestered disc fragment is noted in the right lateral recess of S1.
2. A postero-central and left paracentral disc herniation at the L4-L5 level.
3. Posterior peridiscal osteophytes at the L4-L5 and L5-S1 levels.
4. Bilateral far lateral (extraforaminal) disc herniations at the L5-S1 level.
5. Facetal arthropathy at the L5-S1 level.