Date : 00.00.00
Name of the Patient : Abc Xyza C. Almn / F / 35 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 4-5 months.
Alleged H/O fall prior to this.
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 L5 vertebra is as marked on the film. Please correlate with plain radiographs. The L4-L5 intervertebral disc shows loss of water content.
There is a postero-central disc herniation at the L5-S1 level indenting the dural theca anteriorly.
A postero-central disc herniation with peridiscal osteophytes is noted at the L4-L5 level indenting the anterior dural theca.
Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels. The pedicles of these vertebrae appear congenitally short in their antero-posterior dimensions. Slight ligamentum flavum hypertrophy is noted at the S1 vertebral level.
Schmorls nodes are noted along the superior cortical endplates of the L4 and L5 vertebrae.
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 L2 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
16.0 mm at L3-L4
13.0 mm at L4-L5
11.0 mm at L5-S1.
1. A postero-central disc herniation at the L5-S1 level.
2. A postero-central disc herniation with peridiscal osteophytes at the L4-L5 level.
3. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels with congenitally short pedicles of these vertebrae in their antero-posterior dimensions and a resultant tight canal at these levels.