Date : 00.00.00
Name of the Patient : Abc Xyzali lmn / M / 40 yrs.
Referred by : Dr. Abc Xyz Hashim.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
H/O fall with heavy weight on 00.00.00 with weakness of BLE since then.
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 normal lumbar lordosis and loss of water content of the lumbar intervertebral discs.
There is a posteriorly extruded disc at the L2-L3 level with thecal sac compression. Superior and inferior migration of the disc fragment along the posterior margin of the L2 and L3 vertebral bodies is noted.
A right postero-lateral (foraminal) and far lateral disc herniation is noted at the L3-L4 level with indentation on the right L3 nerve root.
Minimal posterior disc bulges are noted at the L4-L5 and L5-S1 levels.
Slight facetal hypertrophy is noted at the L5-S1 level.
Type II degenerative marrow changes are noted adjacent to the lumbar intervertebral discs.
The remaining facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L2 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
11.0 mm at L1-L2
10.0 mm at L2-L3
11.0 mm at L3-L4
11.0 mm at L4-L5
9.0 mm at L5-S1.
Incidentally noted are multiple small, cortical renal cysts on either side.
1. A posteriorly extruded disc at the L2-L3 level with superior and inferior migration of the disc fragment along the posterior margin of the L2 and L3 vertebral bodies compressing the thecal sac.
2. A right postero-lateral (foraminal) and far lateral disc herniation at the L3-L4 level with indentation on the right L3 nerve root.
3. Slight facetal hypertrophy at the L5-S1 level.