Date : 00.00.00
Name of the Patient : Abc XyzSubblmn / M / 60 yrs.
Referred by : Dr. Abc Xyznkaria / Dr. Abc Xyzhwar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 2 years.
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 normal lumbar lordosis and slight loss of water content of all the lumbar intervertebral discs.
There is a fairly large posterior and right paracentral extruded disc with peridiscal osteophytes at the L5-S1 level with inferior migration of the disc fragment, more to the right of the midline indenting the traversing right S1 nerve root with canal stenosis.
A small posterior disc herniation is noted at the L4-L5 level with bilateral neural foraminal narrowing and tight lumbar canal.
A left far lateral disc bulge is noted at the L3-L4 level with minimal indentation on the extraforaminal segment of the left L3 nerve root.
Slight facetal hypertrophy is noted at the L4-L5 and L5-S1 levels.
A probable right sided conjoint L4 and L5 nerve roots is noted.
Fatty marrow changes are noted in the upper lumbar vertebrae.
The rest of 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 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
15.0 mm at L3-L4
14.0 mm at L4-L5
10.0 mm at L5-S1.
1. A fairly large posterior and right paracentral extruded disc with peridiscal osteophytes at the L5-S1 level with inferior migration of the disc fragment, more to the right of the midline indenting the traversing right S1 nerve root with canal stenosis.
2. A small posterior disc herniation at the L4-L5 level with tight lumbar canal.