Date : 00.00.00
Name of the Patient : Abc Xyzh Valmn / M / 55 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE.
Alleged H/O fall.
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 a large postero-central disc herniation indenting the thecal sac at the L3-L4 level. A small right postero-lateral (foraminal) disc herniation is seen to indent the exiting right L3 nerve root and cause mild right neural foraminal narrowing at this level.
Postero-central disc herniations are seen to indent the thecal sac at the L4-L5 and L5-S1 levels.
A mild posterior disc bulge is noted at the L2-L3 level.
Far lateral (extraforaminal) disc bulges are noted bilaterally at the L3-L4, L4-L5 and L5-S1 levels. Also seen is mild facetal hypertrophy at these levels. The intervertebral discs at these levels show loss of water content.
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.
The conus medullaris terminates at the D12-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 :
15.0 mm at L1-L2
14.0 mm at L2-L3
11.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.
1. A large postero-central disc herniation at the L3-L4 level.
2. Postero-central disc herniations at the L4-L5 and L5-S1 levels.
As compared to the previous MRI dated 00.00.00, there is no significant change noted.