Date : 00.00.00
Name of the Patient : Abc Xyz Dslmn / M / 25 yrs.
Referred by : Dr. Abc Xyzrekh.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 3 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.
There is a small posterior disc herniation with peridiscal osteophytes indenting the thecal sac and causing mild neural foraminal narrowing bilaterally at the L4-L5 level.
A posterior disc bulge with small peridiscal osteophytes is seen at the L5-S1 level.
The L4-L5 and L5-S1 facet joints show degenerative changes.
There appears to be a spina bifida at the S1 vertebral level.
The L4-L5 intervertebral disc shows mild loss of water content.
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 :
19.0 mm at L1-L2
15.0 mm at L2-L3
13.0 mm at L3-L4
12.0 mm at L4-L5
11.0 mm at L5-S1.
The MRI features are suggestive of :
1. A small posterior disc herniation with peridiscal osteophytes at the L4-L5 level.
2. Facetal arthropathy at the L4-L5 and L5-S1 levels.