Date : 00.00.00
Name of the Patient : Abc Xyz lmn / M / 17 yrs.
Referred by : Dr. Abc Xyzhtekar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) with paresthesias since 2 years
H/O fall from a height at the age of 5-6 years.
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 defect in the sacral vertebra with scoliosis and convexity to the right with a pseudo joint formation (?? traumatic ? congenital). The L5 vertebral body is sacralized and the L4 vertebra is as marked on the film. The right ala appears smaller as compared to the left side with a pelvic tilt to the right side. The right lamina of L5 also appears smaller.
Right far lateral disc herniations are seen at the L3-L4 and L4-L5 levels with indentation upon the right L3 and L5 nerve roots, respectively.
There is narrowing of the neural foramen at the L3-L4 level with probable indentation upon the left L3 nerve root.
The lumbar vertebral bodies and the intervertebral discs reveal normal signal intensity. The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The facet joints on the left side at the L4-L5 and L3-L4 levels and bilaterally at the L2-L3 and L1-L2 levels show hypertrophic changes.
The conus medullaris terminates at the D11 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 :
19.0 mm at L1-L2
17.0 mm at L2-L3
12.0 mm at L3-L4
13.0 mm at L4-L5
10.0 mm at L5-S1.
1. Defect in the sacral vertebra with scoliosis and convexity to the right (? congenital ?? traumatic).
2. Sacralized L5 vertebral body and the L4 vertebra is as marked on the film.
3. Right far lateral disc herniations at the L3-L4 and L4-L5 levels with indentation upon the right L3 and L5 nerve roots respectively with narrowing of the left neural foramen at the L3-L4 level.
4. Hypertrophy of the left facet joints at the L4-L5 and L3-L4 levels and bilaterally at the L1-L2 and L2-L3 levels.