Date : 00.00.00
Name of the Patient : Abc Xyza Jarilmn / F / 38 yrs.
Referred by : Dr. Abc Xyznna.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 4 months.
H/O lumbar spine tuberculosis in 0000. Received AKT.
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 evidence of a postero-central disc protrusion indenting the thecal sac at the L5-S1 level.
A posterior disc bulge is noted at the L4-L5 level. Small peridiscal osteophytes are noted at the L4-L5 and L5-S1 levels.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
The L4-L5 and L5-S1 facet joints show mild degenerative changes.
The lumbar vertebral bodies show fatty changes. The remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
Incidental note is made of a retroverted uterus.
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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
14.0 mm at L3-L4
14.0 mm at L4-L5
12.0 mm at L5-S1.
1. A postero-central disc protrusion at the L5-S1 level.
2. A posterior disc bulge at the L4-L5 level.
3. Mild facetal arthropathy at the L4-L5 and L5-S1 levels.