Date : 00.00.00
Name of the Patient : Abc Xyz Manlmn / M / 40 yrs.
Referred by : Dr. Abc Xyzngsarkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O paresthesias in the RLE since 7 months.
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 vertebra and the L1 vertebral body is as marked on the film.
There is a postero-central and left postero-lateral disc herniation at the L4-L5 level with indentation of the thecal sac and left neural foraminal narrowing. There is slight indentation upon both the traversing L5 nerve roots and upon
the exiting left L4 nerve root. The L4-L5 facet joints show degenerative changes. This intervertebral disc shows loss of water content.
Bilateral far lateral (extraforaminal) disc bulges are seen at the L3-L4 and L4-L5 levels.
Type I degenerative changes are seen in the L5 vertebral body adjacent to the L4-L5 intervertebral disc.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of 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 S1 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
14.0 mm at L2-L3
14.0 mm at L3-L4
11.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of the L5 vertebral body.
2. A postero-central and left postero-lateral disc herniation at the L4-L5 level with facetal arthropathy at this level.