Date : 00.00.00
Name of the Patient : Abc XyzNlmn / M / 38 yrs.
Referred by : Dr. Abc Xyz Sane.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with tingling since 0000.
H/O fall in childhood.
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 vertebra and the L3 vertebral body is as marked on the film.
A small, postero-central disc herniation with posterior peridiscal osteophytes with bilateral postero-lateral disc herniations is seen at the L4-L5 level with anterior indentation of the thecal sac. The L4-L5 facet joint on the right side shows mild degenerative changes. This intervertebral disc show loss of water content.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The remaining 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-S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.0 mm at L1-L2
18.0 mm at L2-L3
18.0 mm at L3-L4
13.0 mm at L4-L5
12.0 mm at L5-S1.
1. Partial sacralization of the L5 vertebra.
2. A small, postero-central disc herniation with posterior peridiscal osteophytes with bilateral postero-lateral disc herniations at the L4-L5 level with mild facetal arthropathy on the right side.