Date : 00.00.00
Name of the Patient : Abc XyzSanglmn / M / 32 yrs.
Referred by : Dr. Abc Xyzhah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 1 1/2 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.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show slight loss of water content.
There is a posterior disc herniation at the L5-S1 level to the right of the midline with anterior indentation of the thecal sac and the right S1 nerve root. Mild ligamentum flavum hypertrophy is noted at this level.
A small posterior disc herniation is noted at the L4-L5 level. The L4-L5 facet joints show degenerative changes.
Small posterior peridiscal osteophytes are noted L3-L4, L4-L5 and L5-S1 levels.
Fat is seen in the filum terminale over the L3 to S1 levels - a normal variant.
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 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 :
16.0 mm at L1-L2
16.0 mm at L2-L3
15.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A posterior disc herniation at the L5-S1 level, more to the right of the midline with indentation upon the right S1 nerve root.
2. A small posterior disc bulge at the L4-L5 level with facetal arthropathy at this level.
3. Small posterior peridiscal osteophytes at the L3-L4, L4-L5 and L5-S1 levels.