Date : 00.00.00
Name of the Patient : Abc Xyzr Salmn / M / 65 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE since 1 year.
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 a small posterior disc herniation, slightly to the right of the midline at the L5-S1 level. This disc shows loss of water content.
Small posterior and left postero-lateral disc bulge is noted at the L4-L5 level with anterior indentation of the thecal sac and mild left neural foraminal narrowing.
A left far lateral disc herniation is seen at the L3-L4 level with indentation upon the extraforaminal left L3 nerve root.
Fat is noted within the spinal canal at the L5 level giving the thecal sac a trifoliate appearance and which may be seen with epidural lipomatosis.
The lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. 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 L5 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
15.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
14.0 mm at L4-L5
14.0 mm at L5-S1.
1. A small posterior disc herniation, slightly to the right of the midline at the L5-S1 level.
2. Small posterior and left postero-lateral disc bulge at the L4-L5 level.
3. A left far lateral disc herniation at the L3-L4 level with indentation upon the extraforaminal left L3 nerve root.