Date : 00.00.00
Name of the Patient : Abc Xyzbai Shlmn / F / 35 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 1 year.
H/O fall 1 year ago and injury to neck. Cervical laminectomy was done.
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 mild retroplacement of the L5 vertebra over the S1 vertebra.
There is a postero-central disc herniation, more to the left of the midline and indenting both the traversing S1 nerve roots at the L5-S1 level.
Postero-central disc protrusion is seen to indent the thecal sac at the L4-L5 level. A posterior disc bulge at the L3-L4 level.
The L5-S1 facet joints show mild degenerative changes. The L5-S1 intervertebral disc shows loss of water content.
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 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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
11.0 mm at L3-L4
11.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc herniation, more to the left of the midline and indenting both the traversing S1 nerve roots at the L5-S1 level.
2. Postero-central disc protrusion at the L4-L5 level.
3. Mild facetal arthropathy at the L5-S1 level.
4. Canal stenosis at the L5-S1 level and tight canal at the L4-L5 level.