Date : 00.00.00
Name of the Patient : Abc Xyzra Varlmn / M / 30 yrs.
Referred by : Dr. Abc Xyzenoy.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 5-6 years.
H/O fall 5-6 years back.
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 loss of normal lumbar lordosis and loss of water content of the L4-L5 intervertebral disc. The L4 and L5 vertebrae appear codfish in shape.
There is a posterior and left postero-lateral disc herniation with peridiscal osteophytes at the L4-L5 level with left neural foraminal narrowing (scan 102.1, 102.2, 104.8, 106.6) and probable indentation on the left L4 nerve root.
A minimal posterior disc bulge is seen at the L3-L4 level.
Slight bulge of the L4-L5 and L5-S1 intervertebral discs into the body of L5, centrally is noted.
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 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 :
17.0 mm at L1-L2
16.0 mm at L2-L3
14.0 mm at L3-L4
13.0 mm at L4-L5
14.0 mm at L5-S1.
Degenerated L4-L5 disc with a posterior and left postero-lateral disc herniation with peridiscal osteophytes at that level narrowing the left neural foramen and with probable indentation upon the left L4 nerve root.