Date : 00.00.00
Name of the Patient : Abc XyzShetrlmn / M / 29 yrs.
Referred by : Dr. Abc Xyzah / Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias since 1 year which has increased since 1 1/2 months.
H/O fall from scooter 6-7 months back.
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 normal lumbar lordosis. There is sacralization of the L5 vertebra and the L1 vertebral body is as marked on the film.
There is slight retroplacement of the L4 over the L5 vertebral body. A posterior and left paracentral disc herniation is seen at the L4-L5 level with compression of the thecal sac with resultant canal stenosis. There is resultant left neural foraminal narrowing with indentation upon the exiting left L5 nerve root. There is slight inferior migration of the disc. This disc shows loss of water content. The L4-L5 facet joints bilaterally show degenerative changes.
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 D12-L1 level and the thecal sac terminates at the S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
16.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
7.0 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 posterior and left paracentral disc herniation at the L4-L5 level with facetal hypertrophy and resultant canal stenosis at this level.