Date : 00.00.00
Name of the Patient : Abc XyzGalvalmn / M / 24 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with radiation of pain 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 normal lumbar lordosis. The L4-L5 intervertebral disc shows loss of water content.
A postero-central disc extrusion is seen to indent the thecal sac at the L4-L5 level. A disc portion is seen to lie within the right lateral recess of the L5 vertebra with impingement of the traversing right L5 nerve root. The left L4-L5 facet joint shows mild degenerative changes.
A posterior disc bulge is noted at the L5-S1 level.
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 :
16.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A postero-central disc extrusion at the L4-L5 level with a disc portion lying within the right lateral recess of the L5 vertebra with impingement of the traversing right L5 nerve root.
2. Mild facetal arthropathy on the left side at the L4-L5 level.