Date : 00.00.00
Name of the Patient : Abc Xyz Prlmn / M / 27 yrs.
Referred by : Dr. Abc XyzSonawane.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with paresthesias since 00.00.00.
H/O fall 8 days back.
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 L4-L5 and L5-S1 intervertebral discs.
There is a postero-central disc herniation with peridiscal osteophyte at the L5-S1 level indenting the dural theca anteriorly.
There is a fairly large posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level with thecal sac compression. A sequestered disc fragment is noted in the anterior epidural space at the L4 and L5 vertebral levels (slight superior and inferior migration of the disc fragment is noted) with canal stenosis.
Slight facetal hypertrophy is seen at the L5-S1 level bilaterally.
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 L1-L2 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 :
17.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
05.0 mm at L4-L5
12.0 mm at L5-S1.
1. A fairly large posteriorly extruded disc with peridiscal osteophytes at the L4-L5 level with a sequestered disc fragment in the anterior epidural space at this level with superior and inferior migration of the disc fragment with canal stenosis.
2. A postero-central disc herniation with peridiscal osteophyte at the L5-S1 level with facetal hypertrophy.