Date : 00.00.00
Name of the Patient : Abc Xyzel Calmn / M / 55 yrs.
Referred by : Dr. Abc Xyzdy.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since October 0000.
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 right paracentral disc extrusion at the L4-L5 level with antero-lateral compression of the thecal sac. An extruded disc portion is seen to migrate inferiorly and indent the traversing right L5 nerve root.
A small, right paracentral disc herniation is seen at the L5-S1 level with mild indentation upon the right S1 nerve root.
A small posterior disc bulge is noted at the L3-L4 level. Anterior disc herniations are also noted at this level.
Slight hypertrophy of the facet joints is noted at the L4-L5 level.
The lower lumbar 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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
6.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A right paracentral disc extrusion at the L4-L5 level with inferior migration of the disc fragment indenting the traversing right L5 nerve root.
2. A small, right paracentral disc herniation at the L5-S1 level with mild indentation upon the right S1 nerve root.
3. A small posterior disc bulge at the L3-L4 level.