Date : 00.00.00
Name of the Patient : Abc Xyz lmn / M / 54 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with paresthesias 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.
There is loss of water content of all the lumbar intervertebral discs except the L5-S1 disc.
There is a posteriorly herniated disc at the L4-L5 level with thecal sac compression and bilateral neural foraminal narrowing. Slight inferior migration of the disc fragment is noted in the left lateral recess of L5, indenting the traversing left L5 nerve root.
Small postero-central protruded disc with peridiscal osteophytes is noted at the L1-L2 level.
Slight facetal hypertrophy is noted at the L5-S1 level on the left and at the L3-L4 and L4-L5 levels bilaterally
Type II degenerative marrow changes are noted adjacent to the L2-L3, L3-L4 and L4-L5 intervertebral discs.
The rest of the lumbar vertebral bodies reveal normal signal intensity. The visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the 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 :
13.0 mm at L1-L2
14.0 mm at L2-L3
12.0 mm at L3-L4
10.0 mm at L4-L5
11.0 mm at L5-S1.
1. A posteriorly herniated disc at the L4-L5 level with slight inferior migration of the disc fragment in the left lateral recess of L5, indenting the traversing left L5 nerve root.
2. Small postero-central protruded disc with peridiscal osteophytes at the L1-L2 level.
3. Slight facetal hypertrophy at the L5-S1 level on the left and at the L3-L4 and L4-L5 levels bilaterally.