Date : 00.00.00
Name of the Patient : Abc Xyz Dlmn / M / 28 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
Alleged H/O fall 2 years back.
C/O pain in the left gluteal region with radiation to the LLE since 20 months.
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 sacralization of the L5 vertebra and which is as marked on the film. There appears to be a spina bifida of the L5 vertebra.
There is loss of water content of the L4-L5 intervertebral disc.
There is a fairly large, postero-central and left paracentral extruded disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression and indentation on the traversing left L5 nerve root. Slight inferior migration of the disc fragment is noted.
A minimal posterior disc bulge is noted at the L3-L4 level.
The articular facets at the L2-L3, L3-L4 and L4-L5 levels appear slightly hypertrophied.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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.
Fat is noted in the filum terminale.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
8.0 mm at L4-L5
15.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. A fairly large, postero-central and left paracentral extruded disc with peridiscal osteophytes at the L4-L5 level indenting the traversing left L5 nerve root. Slight inferior migration of the disc fragment is noted.
3. Canal stenosis at the L4-L5 level.