Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 53 yrs.
Referred by : Dr. Abc Xyznna / Dr. Abc Xyzlkan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O trauma to low back.
C/O low back pain radiating to the LLE since 2 months.
M.R.I of the lumbo-sacral spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
4 mm and 5 mm thick T1 Weighted and T2 Weighted axial images.
There is loss of water content of the L4-L5 disc.
A small, postero-central protruded disc is noted at the L4-L5 level.
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 S2 level.
The sacro-coccygeal segments show normal signal. The coccygeal segments appear slightly retroplaced in relation to the sacral segments, with a posterior osteophyte at the sacro-coccygeal junction, ? due to old trauma at the sacro-coccygeal junction.
No bone erosion or destruction is seen.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
15.0 mm at L5-S1.
1. Degenerated L4-L5 disc with a small, postero-central protruded disc at that level.
2. Slight retroplacement of the coccygeal segments in relation to the sacrum with a posterior osteophyte at the sacro-coccygeal junction, ? due to old trauma at the sacro-coccygeal junction.