Date : 00.00.00
Name of the Patient : Abc XyzS. Ablmn / M / 45 yrs.
Referred by : Dr. Abc XyzV. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE 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 loss of water content of the D12-L1, L4-L5 and L5-S1 intervertebral discs.
There is a postero-central and right postero-lateral disc herniation at the L5-S1 level with right neural foraminal narrowing and posterior displacement of the right S1 nerve root.
A postero-central and left postero-lateral disc herniation is noted at the L4-L5 level with left neural foraminal narrowing. Slight inferior migration of the disc fragment is noted with probable indentation on the traversing L5 nerve roots bilaterally, more on the left side. Small posterior peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels.
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 L2 level and the thecal sac terminates at the S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
20.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
11.0 mm at L4-L5
13.0 mm at L5-S1.
1. A postero-central and left postero-lateral disc herniation at the L4-L5 level with slight inferior migration of the disc fragment probably indenting the traversing L5 nerve roots bilaterally, moreon the left side.
2. A postero-central and right postero-lateral disc herniation at the L5-S1 level.
3. Small posterior peridiscal osteophytes at the L4-L5 and L5-S1 levels.