Date : 00.00.00
Name of the Patient : Abc Xyzodalmn / M / 47 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with paresthesias since 4 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 sacralization of the L5 vertebra and the D12 vertebral body is as marked on the film. There is scoliosis of the lumbar spine with convexity to the left side.
There is slight retroplacement of the L4 over the L5 vertebral body.
A large right paracentral disc herniation is seen at the L4-L5 level with antero-lateral indentation of the thecal sac and indentation upon the exiting right L5 nerve root. There is inferior migration of the disc posterior to the L5 vertebra. There is suggestion of the right L5 nerve root being inflamed. This disc shows loss of water content and is reduced in height.
Mild facetal hypertrophy is seen in the lumbar region.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
- 2 - scan-00006
The conus medullaris terminates at the D12-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 :
13.0 mm at L1-L2
12.0 mm at L2-L3
12.0 mm at L3-L4
8.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebra.
2. Slight retroplacement of the L4 over the L5 vertebral body.
3. A large right paracentral disc herniation at the L4-L5 level with indentation upon the exiting right L5 nerve root with inferior migration of the disc posterior to the L5 vertebra with inflammation of the right L5 nerve root.