Date : 00.00.00
Name of the Patient : Abc Xyz Kalmn / F / 35 yrs.
Referred by : Dr. Abc Xyz. Shah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE (right more than left) 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 partial sacralization of the L5 vertebra on the left side and the L1 vertebral body is as marked on the film.
A large postero-central disc extrusion is seen at the L4-L5 level with compression of the thecal sac and canal stenosis.
There is inferior migration of the disc fragment which is seen to lie posterior to the L5 vertebral body. The L4-L5 facet joints show degenerative changes.
A small posterior disc herniation is seen at the L3-L4 level with anterior indentation of the thecal sac. The L3-L4 and L4-L5 intervertebral discs show 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 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 :
17.0 mm at L1-L2
17.0 mm at L2-L3
13.0 mm at L3-L4
8.0 mm at L4-L5
7.0 mm at L5-S1.
The MRI features are suggestive of :
1. Partial sacralization of the L5 vertebra on the left side and the L1 vertebral body is as marked on the film.
2. A large postero-central disc extrusion at the L4-L5 level with canal stenosis and inferior migration of the disc fragment lying posterior to the L5 vertebral body.
3. Facetal arthropathy at the L4-L5 level.
5. A small posterior disc herniation at the L3-L4 level.