Date : 00.00.00
Name of the Patient : Abc Xylmn / M / 18 yrs.
Referred by : Dr. Abc Xyzolakia.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O pain in the joints of the LLE with occasional tingling.
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 L4-L5 and L5-S1 intervertebral discs show loss of water content and appear reduced in height.
There is mild retroplacement of the L5 vertebra over the S1 vertebra. A spina bifida is seen at the S1 level.
A large postero-central disc extrusion is seen to indent the thecal sac and both the traversing L5 nerve roots at the L4-L5 level.
A postero-central disc herniation is seen to indent the traversing left S1 nerve root at the L5-S1 level.
The left facet joint at the L4-L5 and L5-S1 levels shows mild degenerative changes.
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 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 :
15.0 mm at L1-L2
13.0 mm at L2-L3
13.0 mm at L3-L4
5.0 mm at L4-L5
8.0 mm at L5-S1.
The MRI features are suggestive of :
1. A large postero-central disc extrusion with canal stenosis at the L4-L5 level.
2. A postero-central disc herniation at the L5-S1 level.