Date : 00.00.00
Name of the Patient : Abc Xyzharlmn / F / 44 yrs.
Referred by : Dr. Abc Xyzshi.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with numbness since 1 month.
H/O fall 3 years back.
H/O Pulmonary Kochs 2 years back. Received AKT.
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 the L4-L5 and L5-S1 intervertebral discs.
There is a very small, left postero-lateral (foraminal) protruded disc at the L4-L5 level (scans 104.7, 106.6). Small posterior peridiscal osteophytes are noted at this level.
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-L1 level and the thecal sac terminates at the S4 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
19.0 mm at L2-L3
19.0 mm at L3-L4
16.0 mm at L4-L5
16.0 mm at L5-S1.
Screening images of the cervical spine were done with 4 mm thick T2 Weighted sagittal images and 5 mm thick Fast Scan (T2 *) axial images. Right postero-lateral disc herniation is seen at the C4-C5 level and left postero-lateral disc herniations at the C5-C6 and C6-C7 levels. Posterior peridiscal osteophytes are noted at these levels.
Degenerated L4-L5 and L5-S1 discs with a small left postero-lateral (foraminal) protruded disc at the L4-L5 level. Small posterior peridiscal osteophytes are noted at the L4-L5 level.
If clinically indicated, a dedicated study of the cervical spine would be worthwhile.