Date : 00.00.00
Name of the Patient : Abc Xyzi Tlmn / M / 40 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache with pain radiating to BLE with paresthesias since 1 month.
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 lumbar intervertebral discs show loss of water content.
There is evidence of a large postero-central disc extrusion compressing the thecal sac at the L4-L5 level with canal stenosis.
Small postero-central disc protrusions are seen at the L3-L4 and L5-S1 levels.
There is mild facetal hypertrophy at the L3-L4 and L4-L5 levels. Also seen is ligamentum flavum hypertrophy at the L4-L5 level.
The lumbar vertebral bodies 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 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 :
16.0 mm at L1-L2
16.0 mm at L2-L3
16.0 mm at L3-L4
11.0 mm at L4-L5
10.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc extrusion with ligamentum flavum hypertrophy and canal stenosis at the L4-L5 level.
2. Small postero-central disc protrusions at the L3-L4 and L5-S1 levels.
3. Mild facetal hypertrophy at the L3-L4 and L4-L5 levels.