Date : 00.00.00
Name of the Patient : Abc XyzS. Merclmn / M / 35 yrs.
Referred by : Dr. Abc Xyz. Kapadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the RLE since 4-5 days with paresthesias.
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.
4 mm thick T1 Weighted axial images through L5-S1 level.
The gluteal region was screened with 5 mm thick T1 Weighted and STIR axial images.
There is slight retroplacement of the L5 vertebra over the S1 vertebra.
A postero-central disc herniation with peridiscal osteophytes is seen to indent the thecal sac and minimally indent both the traversing S1 nerve roots at the L5-S1 level. A small left postero-lateral (foraminal) disc herniation is seen to narrow the left neural foramina at this level. There appears to be slight inflammation of the traversing left S1 nerve root. A disc fragment is also seen to lie in the right antero-lateral epidural space at the S1 indenting the right S1 nerve root.
The L5-S1 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.
On screening the gluteal region, the hyperintense signal on the STIR images on the left side is most likely the result of an intramuscular injection. The visualized hip joints and sacro-iliac joints are otherwise unremarkable.
The conus medullaris terminates at the L1 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
13.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
18.0 mm at L4-L5
17.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc herniation with peridiscal osteophytes, minimally indenting the traversing S1 nerve roots bilaterally at the L5-S1 level.
2. A small left postero-lateral (foraminal) disc herniation at the L5-S1 level.
3. A small sequestered disc fragment in the right antero-lateral epidural space at the S1 level, indenting the right S1 nerve root.