Date : 00.00.00
Name of the Patient : Abc Xyz Rodrilmn / M / 40 yrs.
Referred by : Dr. Abc Xyzdar.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to BLE with tingling since 6-7 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 reduction in height and loss of water content of the L5-S1 intervertebral disc.
There is a posterior and a left paracentral disc herniation at the L5-S1 level with slight inferior migration of the disc fragment to the left of the midline indenting the traversing left S1 nerve root.
Small posterior peridiscal osteophytes are noted at the L1-L2 level.
Slight facetal hypertrophy is noted at the L3-L4 level on the right.
Type II degenerative marrow changes are noted adjacent to the L5-S1 intervertebral disc and Type I degenerative changes are noted in the L2 vertebral body adjacent to the L1-L2 intervertebral disc.
The rest of 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 intrathecal nerve roots over the L3 to S1 vertebral levels appear clumped suggesting Group I/II arachnoiditis.
The conus medullaris terminates at the L1-L2 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 :
19.0 mm at L1-L2
20.0 mm at L2-L3
19.0 mm at L3-L4
17.0 mm at L4-L5
16.0 mm at L5-S1.
1. A posterior and a left paracentral disc herniation at the L5-S1 level with slight inferior migration of the disc fragment to the left of the midline indenting the traversing left S1 nerve root.
2. Slight facetal hypertrophy at the L3-L4 level on the right.
3. Group I/II arachnoiditis over the L3 to S1 vertebral levels.