Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzaubal / Dr. Abc Xyz>
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache 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 sacralization of the L5 vertebral body and the L2 vertebra is as marked on the film.
There is a small diffuse posterior and right far lateral disc herniation at the L4-L5 level with anterior indentation of the thecal sac. Anterior disc herniation is also noted at this level. This disc shows loss of water content.
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 S1 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
18.0 mm at L1-L2
17.0 mm at L2-L3
17.0 mm at L3-L4
14.0 mm at L4-L5
11.0 mm at L5-S1.
Focal sclerosis is noted in the right iliac bone adjacent to the right sacro-iliac joint.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebral body.
2. A diffuse posterior and right far lateral disc herniation at the L4-L5 level.