Date : 00.00.00
Name of the Patient : Abc Xyz Dlmn / M / 19 yrs.
Referred by : Dr. Abc Xyzshi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 3 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 loss of water content of the L3-L4 and L4-L5 intervertebral discs.
There is a postero-central disc herniation with peridiscal osteophytes at the L5-S1 level.
A posteriorly herniated disc with peridiscal osteophytes is noted at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Hypertrophic facetal arthropathy is also seen at this level with canal stenosis.
A postero-central and right paracentral disc herniation is noted at the L3-L4 level with slight bilateral neural foraminal narrowing.
Facetal hypertrophy is also noted at the L2-L3 and L5-S1 levels.
The pedicles of the lower lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
Schmorls node is seen in the superior aspect of the L4 vertebral body.
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 :
15.0 mm at L1-L2
13.0 mm at L2-L3
11.0 mm at L3-L4
9.0 mm at L4-L5
10.0 mm at L5-S1.
1. A postero-central disc herniation with peridiscal osteophytes at the L5-S1 level.
2. A posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level.
3. A postero-central and right paracentral disc herniation at the L3-L4 level with slight bilateral neural foraminal narrowing.
4. Facetal hypertrophy at the L2-L3, L4-L5 and L5-S1 levels.
5. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions with lumbar canal stenosis over the L3-L4 to L5-S1 levels.