Date : 00.00.00
Name of the Patient : Abc Xyz Jalmn / F / 30 yrs.
Referred by : Dr. Abc Xyzar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 1 year with pain radiating to the RLE with paresthesias since 2 months.
Alleged H/O fall in childhood. Operated in 0000 (Details not available).
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 a fenestration defect of the right lamina of the S1 vertebra.
There is loss of water content of the L2-L3 to L5-S1 intervertebral discs.
There is a small, right paracentral disc herniation at the L5-S1 level, indenting the traversing right S1 nerve root. A sequestered disc fragment is noted in the right neural foramen at the L5-S1 level and right lateral recess of the S1 vertebra.
A fairly large, posteriorly herniated disc is noted at the L4-L5 level with thecal sac compression and indentation on the traversing L5 nerve roots bilaterally.
A fairly large left paracentral disc herniation is noted at the L3-L4 level indenting the traversing left L4 nerve root.
A small, right paracentral disc herniation is seen at the L2-L3 level.
The facet joints at the L4-L5 and L5-S1 levels appear slightly hypertrophied. Bilateral far lateral (extraforaminal) disc bulges are noted at this level.
Fat is noted in the filum terminale at the L2 and L3 vertebral levels.
The marrow of the visualized lumbar and sacral vertebrae appears relatively hypointense when compared to the normal fatty marrow on the T1 Weighted images, but is isointense on the T2 Weighted images suggesting preponderance of red marrow.
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 :
17.0 mm at L1-L2
12.0 mm at L2-L3
6.0 mm at L3-L4
8.0 mm at L4-L5
8.0 mm at L5-S1.
- 3 - Scan-00001
1. Post-operative status.
2. A small, right paracentral herniated disc at the L5-S1 level, indenting the traversing right S1 nerve root with a sequestered disc fragment in the right neural foramen at the L5-S1 level and in the right lateral recess of the S1 vertebra.
3. A fairly large, posteriorly herniated disc at the L4-L5 level indenting the traversing L5 nerve roots bilaterally.
4. A fairly large left paracentral disc herniation at the L3-L4 level indenting the traversing left L4 nerve root.
5. A small, right paracentral disc herniation at the L2-L3 level.
6. Slight facetal hypertrophy at the L4-L5 and L5-S1 levels.
7. Lumbar canal stenosis at the L3-L4 and L4-L5 levels.