Date : 00.00.00
Name of the Patient : Abc Xyza D. Slmn / F / 48 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 15 days.
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 small posterior and right far lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac and right neural foraminal narrowing. There is indentation upon the extraforaminal portion of the exiting right L4 nerve root.
A posterior disc herniation with small posterior peridiscal osteophytes is seen at the L5-S1 level. Bilateral far lateral (extraforaminal) disc bulges are seen at this level.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content. The L5-S1 intervertebral disc is decreased in height.
Type II degenerative changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 intervertebral disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 :
18.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
15.0 mm at L4-L5
12.0 mm at L5-S1.
1. A small posterior and right far lateral disc herniation at the L4-L5 level with indentation upon the extraforaminal portion of the exiting right L4 nerve root.
2. A posterior disc herniation with small posterior peridiscal osetophytes at the L5-S1 level.