Date : 00.00.00
Name of the Patient : Abc XyzM. Plmn / M / 50 yrs.
Referred by : Dr. Abc Xyzcha.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with numbness.
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 loss of water content of the L3-L4, L4-L5 and L5-S1 intervertebral discs.
There is a postero-central and right paracentral disc herniation at the L5-S1 level indenting the traversing right S1 nerve root.
A posteriorly herniated disc is noted at the L4-L5 level with bilateral neural foraminal narrowing. Inferior migration of the disc fragment is noted, to the right of the midline, indenting the traversing right L5 nerve root. The facet joints at this level appear hypertrophied.
A small posterior disc bulge is noted at the L3-L4 level. Anterior disc herniation with anterior peridiscal osteophytes are noted at this level.
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 S2 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
15.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.
1. A postero-central and right paracentral disc herniation at the L5-S1 level indenting the traversing right S1 nerve root.
2. A posteriorly herniated disc at the L4-L5 level with bilateral neural foraminal narrowing with inferior migration of the disc fragment, to the right of the midline and indentation on the traversing right L5 nerve root.
3. Slight facetal hypertrophy at the L4-L5 level with a tight canal at that level.