Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 15 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O pain in the left gluteal region since 2 months with paresthesias in the LLE.
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 scoliosis of the lumbar spine with convexity to the left side.
There is loss of normal lumbar lordosis.
The L4-L5 and L5-S1 intervertebral discs show loss of water content.
A small posterior disc herniation with peridiscal osteophytes is seen to indent the traversing S1 nerve roots, left more than right at the L5-S1 level. Mild neural foraminal narrowing is seen bilaterally at this level.
A left postero-lateral disc protrusion with peridiscal osteophytes is seen to cause mild left neural foraminal narrowing at the L4-L5 level.
The L4-L5 and L5-S1 facet joints show mild degenerative changes.
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 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 :
17.0 mm at L1-L2
18.0 mm at L2-L3
17.0 mm at L3-L4
12.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. A small posterior disc herniation with peridiscal osteophytes at the L5-S1 level.
2. A left postero-lateral disc protrusion with peridiscal osteophytes at the L4-L5 level.
3. Mild facetal arthropathy at the L4-L5 and L5-S1 levels.