Date : 00.00.00
Name of the Patient : Abc Xyz lmn / F / 42 yrs.
Referred by : Dr. Abc Xyzpadia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE.
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, L4-L5 and L5-S1 intervertebral discs.
There is a small, postero-central disc herniation at the L4-L5 level.
Minimal posterior disc bulges are noted at the L3-L4 and L5-S1 levels.
Slight facetal hypertrophy is noted at the L5-S1 level, more so on the right.
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 thecal sac at the L5-S1 and S1 levels has a trefoil appearance and this may represent epidural lipomatosis.
The conus medullaris terminates at the D12-L1 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 :
14.0 mm at L1-L2
12.0 mm at L2-L3
13.0 mm at L3-L4
14.0 mm at L4-L5
12.0 mm at L5-S1.
Fat is noted in the filum terminale over the L2 to L4 vertebral levels.
Incidentally noted is slight widening of the endometrial canal of the uterus, which requires further evaluation, if clinically indicated.
1. A small, postero-central disc herniation at the L4-L5 level.
2. Slight facetal hypertrophy at the L5-S1 level, more so on the right.