Date : 00.00.00
Name of the Patient : Abc Xyza Glmn / F / 37 yrs.
Referred by : Dr. Abc Xyzhatt / Dr. Abc Xyzhipura.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 13 years (on & off) radiating to the RLE since 4-5 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.
There is partial sacralization of the L5 vertebral body with the L5 vertebral body as marked on the film.
There is loss of water content of the L4-L5 and L5-S1 intervertebral discs.
There is a right postero-lateral (foraminal) disc herniation at the L5-S1 level with slight inferior migration of the disc fragment, indenting the traversing right S1 nerve root, which is probably inflamed (scan 105.2-4, 106.4-6, 103.6, 102.6_).
A small, postero-central protruded disc is noted at the L4-L5 level.
The lumbar vertebral bodies appear slightly hypointense when compared to the normal fatty marrow on the T1 Weighted images which may suggest conversion/preponderance of the haemopoietic marrow.
The remaining intervertebral discs reveal normal signal intensity. 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 S1-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
19.0 mm at L1-L2
19.0 mm at L2-L3
17.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.
1. A right postero-lateral (foraminal) disc herniation at the L5-S1 level with slight inferior migration of the disc fragment, indenting the traversing right S1 nerve root, which is probably inflamed.
2. A small, postero-central protruded disc at the L4-L5 level.