Date : 00.00.00
Name of the Patient : Abc Xyz Plmn / M / 45 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain to the RUE with paresthesias.
Alleged H/O fall.
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.
FEW IMAGES SHOW PATIENT MOTION (PATIENT WAS IN SEVERE PAIN).
There is loss of normal lumbar lordosis. There is mild retroplacement of the L5 vertebra over the S1 vertebra.
A large postero-central disc extrusion, more to the right of the midline is seen to indent the thecal sac at the L5-S1 level. A disc portion is seen to lie within the right lateral recess of the S1 vertebra with impingement of the traversing right S1 nerve root.
A small right postero-lateral (foraminal) disc herniation is seen to narrow the right neural foramen at the L5-S1 level.
A mild posterior disc bulge is noted at the L4-L5 level.
The L4-L5 and L5-S1 facet joints show mild degenerative changes.
The L5-S1 intervertebral disc shows loss of water content.
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 :
13.0 mm at L1-L2
13.0 mm at L2-L3
12.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc extrusion, more to the right of the midline at the L5-S1 level with a disc portion lying within the right lateral recess of the S1 vertebra with impingement of the traversing right S1 nerve root.
2. A small right postero-lateral (foraminal) disc herniation at the L5-S1 level.
3. Mild facetal arthropathy at the L4-L5 and L5-S1 levels.