Date : 00.00.00
Name of the Patient : Abc XyzM. Hlmn / F / 70 yrs.
Referred by : Dr. Abc Xyzmani.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the LLE with paresthesias.
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 suggestion of sacralization of L5 vertebra and is as marked on the film.
There is posterior disc herniation at the L4-L5 level with anterior indentation of the thecal sac. The L4-L5 facet joints show gross hypertrophic degenerative changes with resultant effusion. There is indentation upon the left L5 nerve root.
Small posterior disc bulges are seen at the L3-L4 and the L5-S1 levels.
The lumbar intervertebral discs except for the L5-S1 show loss of water content.
A hemangioma with fatty content is seen in the L1 vertebral body on the right side and in the D12 vertebral body on the left side.
The rest of the lumbar vertebral bodies reveal normal signal intensity. 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 :
18.0 mm at L1-L2
17.0 mm at L2-L3
15.0 mm at L3-L4
9.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Sacralization of L5 vertebra and which is as marked on the film.
2. A posterior disc herniation at the L4-L5 level with gross hypertrophic facetal arthropathy and resultant effusion at this level.