Date : 00.00.00
Name of the Patient : Abc Xyz Blmn / M / 45 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE since 1 year.
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 sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film. Please correlate with plain radiographs.
There is mild retroplacement of the L4 vertebra over the L5 vertebra.
There is a postero-central disc herniation, more to the left of the midline with peridiscal osteophytes at the L4-L5 level and indenting the thecal sac and the traversing left L5 nerve root. This disc shows loss of water content. Mild facetal hypertrophy is noted at the L4-L5 level.
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 D12-L1 level and the thecal sac terminates at the S1-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
19.0 mm at L2-L3
21.0 mm at L3-L4
16.0 mm at L4-L5
13.0 mm at L5-S1.
1. Sacralization of the L5 vertebra. Please correlate with plain radiographs.
2. A postero-central disc herniation, more to the left of the midline with peridiscal osteophytes at the L4-L5 level with indentation upon the traversing left L5 nerve root.