Date : 00.00.00
Name of the Patient : Abc Xyza Suratlmn / M / 27 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 7 years with radiation of pain to BLE.
Alleged H/O fall 2 weeks back, since then increase in pain.
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 appears to be sacralization of the L5 vertebra and the L3 and L5 vertebrae are as marked on the film.
There is mild retroplacement of the L4 vertebra over the L5 vertebra.
A small postero-central disc herniation more to the right of the midline is seen to indent the thecal sac at the L4-L5 level. This intervertebral disc shows loss of water content.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 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
18.0 mm at L2-L3
16.0 mm at L3-L4
12.0 mm at L4-L5.
1. Sacralization of the L5 vertebra.
2. A small postero-central disc herniation more to the right of the midline, at the L4-L5 level.