Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 32 yrs.
Referred by : Dr. Abc Xyzhah / Dr. Abc Xyzdi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 15 days.
H/O similar complaints 1 year back from which patient recovered.
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 compression of the thecal sac and mild left neural foraminal narrowing. The L4-L5 facet joints appear mildly hypertrophied with a resultant tight canal. Small posterior peridiscal osteophytes are noted at the L4-L5 level.
Small posterior disc herniation is seen at the L5-S1 level. The L4-L5 and L5-S1 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 also appear slightly hypertrophied 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 :
22.0 mm at L1-L2
21.0 mm at L2-L3
20.0 mm at L3-L4
13.0 mm at L4-L5
14.0 mm at L5-S1.
1. A postero-central disc herniation at the L4-L5 level with slight hypertrophy of the L4-L5 facet joints with resultant tight canal.
2. Small posterior disc herniation at the L5-S1 level.