Date : 00.00.00
Name of the Patient : Abc Xyzed Almn / M / 48 yrs.
Referred by : Dr. Abc Xyzolakia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (left more than right) with numbness in 0000.
Alleged H/O car accident in June 0000.
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 evidence of a left paracentral disc herniation indenting the thecal sac at the L4-L5 level.
A postero-central protruded disc is noted at the L1-L2 level.
There is a posterior bulge indenting the thecal sac at the L5-S1 level.
The L5-S1 facet joints mild degenerative changes.
The L1-L2, L4-L5 and L5-S1 intervertebral discs show loss of water content.
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 :
21.0 mm at L1-L2
22.0 mm at L2-L3
20.0 mm at L3-L4
18.0 mm at L4-L5
18.0 mm at L5-S1.
1. A left paracentral disc herniation at the L4-L5 level.
2. A postero-central protruded disc at the L1-L2 level.
3. A posterior disc bulge at the L5-S1 level.
As compared to the previous MRI (study no:0000) dated 00.00.00, there is an increase in the size of the disc herniation at the L4-L5 level.