Date : 00.00.00
Name of the Patient : Abc Xyzdin D. lmn / M / 56 yrs.
Referred by : Dr. Abc Xyzauhan.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O low back pain (off and on) since several years which has increased since 8 days radiating to the RLE.
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 L1-L2, L4-L5 and L5-S1 intervertebral discs.
There is slight retroplacement of the L4 over the L5 and L5 over the S1 vertebrae.
There is a posteriorly bulging disc with posterior peridiscal osteophyte at the L5-S1 level. A left far lateral disc herniation is also noted at this level.
A postero-central and right paracentral disc herniation with peridiscal osteophyte is noted at the L4-L5 level indenting the dural theca anteriorly and the traversing right L5 nerve root.
Type II degenerative changes are seen adjacent to the L5-S1 disc.
A hemangioma with fat content is noted in the D12 vertebral body.
The rest of 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 S1 level.
Incidentally noted is fat in the filum terminale at the L2 and L3 vertebral levels.
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
16.0 mm at L3-L4
9.0 mm at L4-L5
13.0 mm at L5-S1.
1. A postero-central and right paracentral disc herniation with peridiscal osteophyte at the L4-L5 level indenting the traversing right L5 nerve root.
2. A posteriorly bulging disc with posterior peridiscal osteophyte at the L5-S1 level with a left far lateral disc herniation at this level.