Date : 00.00.00
Name of the Patient : Abc XyzShlmn / F / 45 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 00.00.00.
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.
3 mm thick T1 Weighted axial images at the L4-L5 level.
There appears to be sacralization of the L5 vertebra and the L1 vertebra is as marked on the film.
There is mild retroplacement of the L4 vertebra over the L5 vertebra.
A postero-central disc herniation is seen to indent the thecal sac at the L4-L5 level. Inferior migration of the disc is identified posterior to the L5 vertebral body. A left postero-lateral (foraminal) disc herniation is seen to indent the exiting left L4 nerve root and narrow the left neural foramen at this level.
The L4-L5 intervertebral disc shows loss of water content.
Mild facetal hypertrophy is noted at the L4-L5 level.
A mild posterior disc bulge is seen at the L3-L4 level.
Focal fat deposition is identified in the D12 and L2 vertebrae.
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 :
20.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. A postero-central disc herniation at the L4-L5 level with a left postero-lateral (foraminal) disc herniation indenting the exiting left L4 nerve root at this level.