Date : 00.00.00
Name of the Patient : Abc Xyz Selmn / M / 49 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 6-7 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.
5 mm thick T1 Weighted and T2 Weighted axial images.
There is a postero-central disc herniation compressing upon the thecal sac at the L3-L4 level. There is facetal arthropathy at this level.
There is a small posterior disc bulge at the L4-L5 level.
There is a small left paracentral disc protrusion indenting the traversing left S1 nerve root at the L5-S1 level.
A small postero-central disc herniation is seen at the L2-L3 level.
The L4-L5 facet joints bilaterally and on the right side at the L2-L3 level show degenerative changes.
Bilateral far lateral (extraforaminal) disc bulges are noted at the L3-L4, L2-L3, and L4-L5 levels.
The L2-L3, L3-L4 and L5-S1 intervertebral discs 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 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 :
14.0 mm at L1-L2
11.0 mm at L2-L3
7.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
1. A postero-central disc herniation with facetal arthropathy and canal stenosis at the L3-L4 level.
2. A small left paracentral disc protrusion indenting the traversing left S1 nerve root at the L5-S1 level.
3. A small postero-central disc herniation at the L2-l3 level.
4. Facetal arthropathy on the right side at the L2-L3 level and bilaterally at the L4-L5 level.