Date : 00.00.00
Name of the Patient : Abc Xyzsh lmn / M / 28 yrs.
Referred by : Dr. Abc Xyzaubal.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 3-4 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 at the L4-L5 level with anterior indentation of the thecal sac. There is slight inferior migration of the disc fragment which is seen to lie posterior to the superior margin of the L5 vertebral body.
A small postero-central disc herniation is seen at the L5-S1 level.
The L4-L5 and L5-S1 intervertebral discs show loss of water content.
Posterior peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels.
The L4-L5 facet joint on the left side and L5-S1 facet joints bilaterally show mild degenerative changes.
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.
- 2 - scan-00006
The conus medullaris terminates at the L1-L2 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 :
17.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
12.0 mm at L5-S1.
Fat is noted in the filum terminale at the L4 vertebral body.
The MRI features are suggestive of :
1. A postero-central disc herniation at the L4-L5 level with slight inferior migration of the disc fragment which is seen to lie posterior to the superior margin of the L5 vertebral body.
2. A small postero-central disc herniation at the L5-S1 level.
3. Posterior peridiscal osteophytes at the L4-L5 and L5-S1 levels.