Date : 00.00.00
Name of the Patient : Abc Xyz Mlmn / M / 40 yrs.
Referred by : Dr. Abc Xyznadkat.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) since 7 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.
The L5 vertebral body is as marked on the film.
There is a right paracentral disc herniation at the L5-S1 level with antero-lateral indentation of the thecal sac and right neural foraminal narrowing. There is a large posterior peridiscal osteophyte at this level.
There is a small postero-central disc herniation with peridiscal osteophyte at the L4-L5 level with mild anterior indentation of the thecal sac. The L4-L5 and L5-S1 intervertebral discs show loss of water content.
Posterior peridiscal osteophytes are noted at the L1-L2 level to the left of the midline.
Type II degenerative changes are noted in the S1 vertebral body adjacent to the L5-S1 intervertebral disc.
The rest of 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 L1 level and the thecal sac terminates at the S3 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
20.0 mm at L1-L2
19.0 mm at L2-L3
19.0 mm at L3-L4
17.0 mm at L4-L5
15.0 mm at L5-S1.
The MRI features are suggestive of :
1. A right paracentral disc herniation with peridiscal osteophytes at the L5-S1 level with right neural foraminal narrowing.
2. A small postero-central disc herniation with peridiscal osteophytes at the L4-L5 level.
3. A left paracentral peridiscal osteophyte at the L1-L2 level.