Date : 00.00.00
Name of the Patient : Abc Xyzt lmn / F / 30 yrs.
Referred by : Dr. Abc Xyzashe.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since January 0000.
H/O fall in December 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 loss of water content of the L4-L5 and L5-S1 intervertebral discs. Slight retroplacement of the L5 over the S1 vertebra is noted.
There is a fairly large right paracentral extruded disc at the L5-S1 level indenting the traversing right S1 nerve root.
A postero-central disc herniation is noted at the L4-L5 level indenting the dural theca anteriorly.
The facet joints at the L5-S1 level appear slightly hypertrophied.
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-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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
11.0 mm at L4-L5
6.0 mm at L5-S1.
1. A fairly large right paracentral extruded disc at the L5-S1 level indenting the traversing right S1 nerve root.
2. A postero-central disc herniation at the L4-L5 level.
3. Slight hypertrophy of the facet joints at the L5-S1 level.