Date : 00.00.00
Name of the Patient : Abc Xyz Darulmn / M / 38 yrs.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with tingling.
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 reduction in height of the L5-S1 intervertebral disc and loss of water content of the L4-L5 and L5-S1 intervertebral discs. Slight retroplacement of the L5 over the S1 vertebrae is noted.
There is a postero-central disc herniation with peridiscal osteophyte at the L5-S1 level with inferior migration of the disc fragment, minimally indenting the traversing S1 nerve roots bilaterally.
A small posteriorly herniated disc with peridiscal osteophytes is noted at the L4-L5 level with slight bilateral neural foraminal narrowing.
Slight facetal hypertrophy is noted at the L3-L4, L4-L5 and L5-S1 levels.
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
17.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.
Screening, T1 Weighted coronal images of the S. I. joints do not reveal any significant feature of note.
1. A postero-central disc herniation with peridiscal osteophyte at the L5-S1 level with inferior migration of the disc fragment, minimally indenting the traversing S1 nerve roots bilaterally.
2. A small posteriorly herniated disc with peridiscal osteophytes at the L4-L5 level.
3. Slight facetal hypertrophy at the L3-L4, L4-L5 and L5-S1 levels.
27th July 0000
Dear Dr. Abc Xyz
Thankyou for referring to us Mr. Dinyar Daruwala, male, aged 35 years, for a MRI of the Lumbo-sacral Spine.
His report and films were sent to you. A comparative report could not be given at that time as the patient had not brought his previous MRI scans.
As compared to the previous MRI dated 00.00.0000, the L5-S1 disc is now reduced in height. There is an increase in the degree of the disc herniation of the L5-S1 disc with minimal indentation on the traversing S1 nerve roots bilaterally.
The status of the L4-L5 disc is largely unchanged.
Thankyou once again for your kind reference.