Date : 00.00.00
Name of the Patient : Abc Xyz lmn / M / 31 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias since 10 months.
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.
SOME T1 AXIAL IMAGES SHOW PATIENT MOTION.
There is sacralization of the L5 vertebra and the L2 vertebral body is as marked on the film.
There is a postero-central disc herniation at the L4-L5 level with posterior peridiscal osteophytes. Inferior migration of the disc is noted. This intervertebral disc shows loss of water content. The L4-L5 facet joints show mild degenerative changes. There is mild posterior displacement of the left L5 nerve root.
A small posterior disc bulge is noted at the L3-L4 level.
Type II degenerative changes are noted in the L4 and L5 vertebrae adjacent to the L4-L5 intervertebral disc.
An area of fat deposition is also noted in the S2 vertebral body.
The rest of 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 level and the thecal sac terminates at the L5 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
16.0 mm at L2-L3
16.0 mm at L3-L4
14.0 mm at L4-L5
10.0 mm at L5-S1.
1. Sacralization of the L5 vertebra.
2. A postero-central disc herniation at the L4-L5 level with posterior peridiscal osteophytes.