Date : 00.00.00
Name of the Patient : Abc XyzHlmn / M / 37 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE (left more than right) since 1 1/2 years.
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 a large, postero-central disc extrusion at the L3-L4 level with severe compression of the thecal sac and resultant canal stenosis. There is slight inferior migration of the disc.
A postero-cental disc extrusion is also seen at the L4-L5 level with anterior indentation of the thecal sac and mild right neural foraminal narrowing. Inferior migration of this disc is also noted.
Posterior disc bulges are noted at the L2-L3 and L5-S1 levels. Bilateral far lateral (extraforaminal) disc bulges are seen at the L3-L4, L4-L5 and L5-S1 levels.
The lumbar facet joints show degenerative changes.
The L3-L4 and L4-L5 intervertebral discs show loss of water content.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1 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 :
15.0 mm at L1-L2
15.0 mm at L2-L3
6.0 mm at L3-L4
8.0 mm at L4-L5
17.0 mm at L5-S1.
1. A large, postero-central disc extrusion at the L3-L4 level.
2. A postero-cental disc extrusion at the L4-L5 level.
3. Degenerative changes of the lumbar facet joints.
4. Canal stenosis at the L3-L4 and L4-L5 levels.