Date : 00.00.00
Name of the Patient : Abc XyzJalmn / M / 45 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with tingling since 1 1/2 years.
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.
The L2 vertebra is as marked on the film. (Kindly correlate with plain radiographs-? sacralization of L5).
The L2-L3, L3-L4 and L4-L5 intervertebral discs show loss of water content.
There is a postero-central disc herniation at the L4-L5 level with mild indentation upon the L5 nerve roots bilaterally. There appears to be posterior displacement of the left L5 nerve root and which appears to be of slightly larger calibre ? inflammation. The L4-L5 facet joints show mild degenerative changes.
Ligamentum flavum hypertrophy is seen at the L5 level.
A small posterior disc bulge is seen at the L3-L4 level.
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
14.0 mm at L2-L3
13.0 mm at L3-L4
10.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of a postero-central disc herniation at the L4-L5 level with mild indentation upon the L5 nerve roots bilaterally with ? inflammation of the left L5 nerve root.