Date : 00.00.00
Name of the Patient : Abc Xyzn Thlmn / M / 43 yrs.
Referred by : Dr. Abc Xyzhari.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 2 1/2 months.
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 slight loss of water content of the L4-L5 intervertebral disc.
A small, postero-central protruded disc is noted at the L5-S1 level.
A posteriorly herniated disc is noted at the L4-L5 level with thecal sac compression. A sequestered disc fragment is noted in the left postero-lateral epidural space at the L4-L5 level with indentation on the traversing left L5 nerve root.
Small posterior disc bulge is noted at the L3-L4 level.
The facet joints at the L4-L5 and L5-S1 levels appears slightly hypertrophied.
The pedicles of the lower lumbar vertebrae appear congenitally short in their antero-posterior dimensions.
Schmorls nodes are noted in the lumbar region.
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 :
14.0 mm at L1-L2
11.0 mm at L2-L3
11.0 mm at L3-L4
10.0 mm at L4-L5
12.0 mm at L5-S1.
1. A posteriorly herniated disc at the L4-L5 level with a sequestered disc fragment in the left postero-lateral epidural space at the L4-L5 level indenting the traversing left L5 nerve root.
2. A small, postero-central protruded disc at the L5-S1 level.
3. Small posterior disc bulge at the L3-L4 level.
4. Slight hypertrophy of the facet joints at the L4-L5 and L5-S1 levels.
5. Congenitally short pedicles of the lower lumbar vertebrae in their antero-posterior dimensions with canal stenosis at the L3-L4 and L4-L5 levels.