Date : 00.00.00
Name of the Patient : Abc Xyz Malmn / M / 18 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with tingling in BLE since 1 month.
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 a posterior disc herniation at the L3-L4 level with anterior indentation of the thecal sac and a tight canal.
There is suggestion of a break of the postero-inferior margin of the L3 vertebral body with slight posterior superior displacement of the fractured fragment (? traumatic disc rupture).
Small posterior disc bulges are seen at the L1-L2 and L2-L3 levels with Schmorls nodes. The L1-L2, L2-L3 and L3-L4 intervertebral discs show loss of water content.
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-L1 level and the thecal sac terminates at the S2 level.
- 2 - Scan-00009
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
14.0 mm at L2-L3
8.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation at the L3-L4 level
with a tight canal.
2. Probable fracture of the postero-inferior margin of the L3 vertebral body (? due to traumatic disc rupture). Correlation with plain radiographs would be worthwhile.