Date : 00.00.00
Name of the Patient : Abc XyzPlmn / M / 36 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE since 00.00.00.
Alleged H/O fall in 0000 with backache. Recovered with traction.
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 loss of water content of the L3-L4 and L4-L5 intervertebral discs.
There is a postero-central and left paracentral extruded disc at the L4-L5 level with indentation on the dural theca anteriorly and on the traversing left L5 nerve root. Slight facetal hypertrophy is noted at that level.
A small postero-central disc herniation is seen at the L3-L4 level, with mild facetal hypertrophy.
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 L1 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 :
19.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
11.0 mm at L4-L5
17.0 mm at L5-S1.
1. A postero-central and left paracentral extruded disc at the L4-L5 level with indentation on the traversing left L5 nerve root.
2. A small postero-central disc herniation at the L3-L4 level.
3. Slight facetal hypertrophy at the L4-L5 and L3-L4 levels.