Date : 00.00.00
Name of the Patient : Abc Xyz Ayub lmn / F / 24 yrs.
Referred by : Dr. Abc Xyzrkar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache since 6 months.
H/O fall from a scooter 4-5 months back.
C/O radicular pain to the RLE with paresthesias since 15 days with bladder involvement since 4-5 days.
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.
The L5-S1 intervertebral disc shows loss of water content and is reduced in height.
There is a large postero-central disc extrusion at the L5-S1 level with severe compression of the thecal sac and canal stenosis. There is indentation on the traversing S1 nerve roots. There is rupture of the posterior longitudinal ligament. Small posterior peridiscal osteophytes are seen at this level.
Type II degenerative changes are noted in the L5 and S1 vertebral bodies adjacent to the L5-S1 disc.
A small posterior disc bulge is identified at the L4-L5 level.
The rest of 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 S2 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
19.0 mm at L2-L3
18.0 mm at L3-L4
15.0 mm at L4-L5
3.0 mm at L5-S1.
A large postero-central disc extrusion at the L5-S1 level with severe compression of the thecal sac and canal stenosis with indentation on the traversing S1 nerve roots.