Date : 00.00.00
Name of the Patient : Abc Xyzlmn / M / 40 yrs.
Referred by : Dr. Abc Xyzarkar / Dr. Abc Xyzt.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE with numbness since 2 months.
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 loss of water content of all the lumbar intervertebral discs except the L5-S1 disc.
There is a fairly large right postero-lateral and right far lateral disc herniation at the L4-L5 level with right neural foraminal narrowing and indentation on the traversing right L5 nerve root and on the extraforaminal segment of the right L4 nerve root.
Small posterior disc bulges with peridiscal osteophytes are noted at the L1-L2, L2-L3 and L3-L4 levels.
Slight retroplacement of the L1 over the L2 vertebra and L2 over the L3 vertebra is noted.
Slight facetal hypertrophy is noted at the L4-L5 level bilaterally and at the L5-S1 level on the left.
Anterior peridiscal osteophytes are seen in the lumbar region with anterior disc herniations over the L1-L2 to L3-L4 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.
Schmorls nodes are seen in the lumbar region and at the D12 level.
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
15.0 mm at L2-L3
14.0 mm at L3-L4
12.0 mm at L4-L5
10.0 mm at L5-S1.
A fairly large right postero-lateral and right far lateral disc herniation at the L4-L5 level with indentation on the traversing right L5 nerve root and on the extraforaminal segment of the right L4 nerve root.