Date : 00.00.00
Name of the Patient : Abc Xyz Deoruklmn / F / 30 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 1 1/2 months.
Alleged H/O fall 5-6 years ago.
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 appears to be sacralization of the L5 vertebra and it is as marked on the film. Please correlate with plain radiographs.
The L4-L5 and L5-S1 intervertebral discs show loss of water content.
There is a posteriorly herniated disc at the L5-S1 level, indenting the dural theca and the traversing S1 nerve roots bilaterally.
A postero-central disc herniation is noted at the L4-L5 level. Mild facetal hypertrophy is noted at this 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 D12 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 :
18.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
10.0 mm at L4-L5
5.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A posteriorly herniated disc at the L5-S1 level indenting the traversing S1 nerve roots bilaterally.
3. A postero-central disc herniation at the L4-L5 level.